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TIONS  OF 

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TERNAL MEDICINE 

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THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


TRANSACTIONS 

OF  THE 

AMERICAN  CONGRESS 

ON 

INTERNAL  MEDICINE 


FIRST  SCIENTIFIC  SESSION,   NEW  YORK  CITY 
DECEMBER  28—29,  1916 


Edited  by 
HEINRICH  STERN 

Assisted  by 
EDWARD  E.  CORNWALL 


Published  for  the  Congress  by  the  Burr  Printing  House,  New  York 
Nineteen  Hundred  and  Seventeen 


Bioraedicaf 

lAtUTf 

I'm 


34 


OFFICERS  1916-1917 

Reynold  Webb  Wilcox.   President,  New  York. 
Elias  H.  Bartley,  Vice-President,   Brooklyn,   New  York. 
Heinrich    Stern,    Secretary-General,    New    York. 
Augustus   Caille,   Treasurer,   New    York. 


COUNCILORS  1916-1917 

Charles  D.  Aaron,  Detroit. 

James   Al.  Anders,   Philadelphia. 

Noble   P.  Barnes,  Washington,  D.  C. 

Henry   Wald   Bcttmann,   Cincinnati,   Ohio. 

Louis  Faugeres   Bishop,   New  York. 

Harlow   Brooks,   New  York. 

Joseph  Henry  Byrne,  New  York. 

Edward   E.   Cornwall,   Broklyn,   New   York. 

Judson  Daland,   Philadelphia. 

Britton   D.   Evans,  Alorristown,  N.  J. 

Henry  A.  Fairliairn,  Brooklyn,  New  York. 

Charles  Lyman  Greene,  St.  Paul,  Minn. 

John   C.   Hemmeter,   Baltimore. 

Clement  R.  Jones,   Pittsburgh. 

Philip    Coomljs    Knapp,   Boston. 

John    A.    Lichty,    Pittsburgh. 

William   H.    Mercur,    Pittsburgh. 

Francis   M.   Pottenger,   Monrovia,   Cal. 

Thomas   F.   Reilly,   New  York. 

Charles  E.   de   AL   Sajous,   Philadelphia. 

Thomas  E.   Satterthwaite,   New   York. 

William   H.   Stewart,   New   York. 

Henry  Enos  Tuley,   Louisville,   Ky. 

Joshua  AL  Van  Cott,  Brooklyn,  New  York. 

Douglas  Vander  Hoof.  Richmond,  Va. 


CONTENTS 

PAGE 

List  of   Officers 3 

Address  of  Welcome  by  Thomas  E.  Satterthwaite 7 

Response  to  Address  of  Welcome,  by  Charles  D.  Aaron 8 

Address  of  President,  Reynold  W.  Wilcox 9 

Discussion  of  the  President's  Address,  by  L.  F.  Bishop,  J.  C. 
Hemmeter,  C.  E.  de  M.  Sajous,  W.  B.  Stewart,  W.  H. 
Mercur,  Briggs,  R.  H.  Babcock  and  J.  Diner 22 

Report  of  the  Secretary-General,  Heinrich  Stern 24 

Report  of  the  Treasurer,  Augustus  Caille 2^] 

Obituaries  of  P.  B.  Porter  and  F.  H.  Daniels,  by  L.  F.  Bishop.  27 

Officers  elected  for  ensuing  year 29 

The  Ductless  Glands  in  Cardiovascular  Diseases  and  Dementia 

Precox,  by  Charles  E.  de  M.  Sajous 30 

Cardiovascular  Diseases  and  the  Ductless  Glands,  by  Judson 

Daland    49 

Dementia   Praecox   and    the   Ductless   Glands,   by    Francis   X. 

Dercum  54 

Discussion  of  the  papers  on  Ductless  Glands,  Cardiovascular 
Diseases  and  Dementia  Praecox,  by  Harlow  Brooks,  S.  E. 
Jeliffe,  Robert  H.  Babcock,  Ernest  Zueblin,  Tom  Williams, 
Francis  X.  Dercum  and  C.  E.  de  M.  Sajous 61 

The  Diagnosis  of  Duodenal  Ulcer,  by  John  B.  Deaver 72 

The  Prognosis  of  Duodenal  Ulcer,  by  Max  Einhorn 78 

The  Possible  Dependence  of  Gastro-Duodenal  Ulcer   Upon  a 

Disturbance  of  Internal  Secretion,  by  Gedide  A.  Friedman     80 

Venous  Stasis  and  Colloidal  Diffusion  as  Etiological  Factors  of 

Gastro-Duodenal   Ulcer,  by   Fenton   B.    Turck 94 

Discussion  of  Gastric  and  Duodenal  Ulcer,  by  J.  C.  Hemmeter, 
I.  Kaufmann,  G.  Lenox  Curtis,  J.  R.  Verbrycke,  J.  W. 
Weinstein,  W.  J.  Mallory.  W.  H.  Stewart,  M.  Gross, 
G.  A.  Friedman  and  F.  B.  Turck 103 


TRANSACTIONS  OF 

THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE, 

FIRST  SCIENTIFIC  SESSION 


DECEMBER  28-29,  1916, 

HOTEL  ASTOR,   NEW  YORK 


The  Congress  was  called  to  order  at  11  A.  M.,  December  28, 
1916,  by  the  President,  Dr.  Reynold  Webb  Wilcox. 

The  President  called  on  Dr.  Thomas  E.  Satterthwaite,  of  New 
York,  to  welcome  the  out-of-town  members. 

Dr.  Satterthwaite:  On  behalf  of  the  New  York  members,  we 
welcome  you  all,  from  various  parts  of  the  country,  to  this  first 
meeting  of  the  American  Congress  on  Internal  Medicine,  the  ses- 
sions of  which  begin  now  and  last  to-day  and  to-morrow. 

A  good  many  of  us  have  felt  that  there  is  great  need  for  a  con- 
gress of  this  kind,  and  the  number  of  men  who  have  joined  is  an 
index  that  we  were  correct  in  that  respect.  The  proceedings  of 
to-day  will  begin  with  an  address  by  our  President,  Dr.  Wilcox, 
and  I  will  say  that  we  should  be  very  glad  that  Dr.  Wilcox  is  our 
President,  because  he  is  one  who  will  organize  the  congress  in  a 
way  that  will  make  it  a  success. 

Following  the  President's  Address,  we  shall  have  a  paper  on 
"The  Ductless  Glands  in  Cardio- Vascular  Diseases  and  Dementia 
Precox,"  by  Charles  E.  de  M.  Sajous,  who  as  we  all  know,  is  an 
authority  on  this  subject. 

Then  we  shall  take  up  the  subject  of  Duodenal  Ulcer,  and  John 
B.  Deaver,  of  Philadelphia,  the  great  authority  on  surgical  diagnosis, 
will  be  the  first  to  speak,  and  he  will  be  followed  by  Max  Einhorn, 
Gedide  A.  Friedman  and  Fenton  B.  Turck,  of  this  city. 

Gentlemen,  I  will  say  no  more,  as  there  is  a  great  deal  before  us 
to  do.  I  hope  that  we  shall  have  a  very  successful  meeting,  and  I 
am  quite  sure  that  we  shall. 

The  President  called  on  Charles  D.  Aaron,  of  Detroit,  to  re- 
spond for  the  out-of-town  members. 

7 


8         THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

Dr.  Aaron,  of  Detroit:  On  behalf  of  the  out-of-town  members, 
I  would  say  that  we  appreciate  greatly  the  privilege  of  being  here  to 
meet  the  more  prominent  internists  in  New  York  and  its  vicinity. 
By  their  very  presence  here  the  out-of-town  members  show  their 
appreciation  of  the  invitation  extended  to  them  to  be  with  you 
to-day. 

Great  credit  should  be  extended  to  the  officers  and  councillors  of 
the  American  Congress  on  Internal  Medicine  for  the  enormous 
amount  of  work  which  they  have  done  in  laying  the  foundation  for 
this  great  enterprise.  The  out-of-town  members  realize  more  than 
they  can  express  that  an  association  of  this  kind  is  more  important 
to  them  than  it  is  to  the  physicians  of  New  York.  It  is  important 
that  the  internists  of  the  United  States  should  come  forward  in 
their  effort  to  raise  the  standard  of  medicine,  and  the  out-of-town 
members  realize  more  than  ever  that  it  is  only  by  co-operation  in 
the  way  that  the  officers  and  councillors  have  started  this  Associa- 
tion, that  the  standard  and  recognition  of  internal  medicine  will  be 
made  greater  than  it  ever  has  been,  and  that  the  laity  will  be  taught 
to  appreciate  the  internist  equally  as  well  as  the  surgeon.  I  can  tell 
you  a  story,  gentlemen,  of  an  incident  that  took  place  in  my  own 
city  this  present  year.  There  was  a  woman,  who  with  her  son, 
came  from  St.  Louis  to  Detroit  and  went  to  a  summer  resort  up  the 
river.  Her  son  was  taken  down  with  typhoid  fever.  Immediately 
the  wife  wired  her  husband  at  St.  Louis  to  know  what  physician  in 
Detroit  it  was  advisable  for  her  to  consult  for  the  care  of  that 
typhoid  fever  case.  The  husband  made  inquiry  in  St.  Louis  and 
found  that  the  most  prominent  physician  in  Detroit  was  a  surgeon, 
and  he  wired  to  his  wife,  "Call  on  Dr.  So  and  So,"  naming  one  of 
our  prominent  surgeons.  She  took  the  telegram,  walked  up  to  the 
clerk  of  the  hotel  and  said,  "Do  you  know  Dr.  So  and  So?"  The 
clerk  said,  "I  certainly  do."  "Is  he  a  good  physician?"  The  clerk 
said,  "One  of  the  very  best."  She  went  to  some  other  Detroiters 
and  asked  the  same  question,  and  they  all  said  he  was  the  very  best. 
She  immediately  telephoned  to  the  surgeon  that  she  was  coming  to 
Detroit  with  this  invalid,  her  son.  The  surgeon  met  the  typhoid 
patient  with  an  ambulance  and  took  him  to  the  hospital.  He  said : 
"What  can  I  do  ?  The  husband  demands  this  from  St.  Louis.  The 
people  here  demand  it.  They  feel  as  though  the  whole  recovery  of 
this  typhoid  fever  case  depends  upon  me.  If  I  turn  this  case  down, 
it  is  going  to  be  a  disappointment  to  them  all,  and  so  I  must  keep  it." 
Gentlemen,  I  hope  that  the  Congress  on  Internal  Medicine  will  do 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE         9 

something  to  prevent  things  of  that  sort ;  and  I  hope  that  this 
initial  movement  will  be  crowned  with  great  success.  I  do  not  want 
to  take  too  much  time,  but  I  could  say  a  great  deal  more.  How- 
ever, we  feel  convinced  that  this  movement,  thus  started,  is  just 
what  we  desire.  * 

The  President  asked  the  Vice-President,  Dr.  E.  H.  Bartley,  to 
take  the  chair. 

The  President,  Dr.  R.  W.  Wilcox,  read  the  following  address: 

THE  FIELD  OF  INTERNAL  MEDICINE 

By   REYNOLD   WEBB   WILCOX, 
New  York 

It  is  an  occasion  of  more  than  ordinary  importance  when  the 
American  Congress  on  Internal  Medicine  convenes  for  its  second 
annual  meeting,  which  is,  however,  its  first  scientific  session.  It 
has  completed  its  physical  organization  and  now  presents  its  scien- 
tific programme.  Its  organization  marks  a  new  era  in  American 
medicine,  and  the  programme  which  has  been  chosen  determines  a 
new  standard  for  scientific  work  in  the  profession  of  which  we  are 
the  exponents. 

The  organization  of  this  Congress  does  not  signify  the  differen- 
tiation of  a  new  specialty,  but  the  delimitation  of  the  oldest  branch 
of  the  healing  art,  for  it  is  probable  that  disease  received  earlier 
attention  than  injury.  Whatever  may  be  the  fact,  it  is,  however, 
true  that  medicine  and  surgery  were  yet  undifferentiated  in  prac- 
tice throughout  the  era  of  the  prehistoric  man,  and  even  for  many 
centuries  thereafter.  As  war  became  more  and  more  an  organized 
operation  and  campaigns  were  planned,  the  care  of  the  wounded 
devolved  upon  the  practitioner  of  the  healing  art,  and  surgery  be- 
came differentiated  in  name  as  well  as  practice,  and  the  chief  sur- 
geon of  the  army  was  often  the  physician  of  the  ruling  prince  or 
king.  Nor,  indeed,  did  his  professional  title  always  change,  for 
even  so  late  as  the  War  of  the  Revolution  in  this  country  the  title 
of  the  medical  officer  w^as  physician  and  not  surgeon.  Yet  today 
in  the  army  the  title  of  surgeon  prevails,  while  the  more  important 
work  of  the  military  practitioner,  whether  considered  from  the 
combatant  or  the  altruistic  standpoint,  is  medical  rather  than  surgical. 

What  then  is  the  domain  of  internal  medicine?  Shall  we  de- 
fine it  as  what  remains  after  surgery  and  the  narrower  specialties. 


10        THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

as  ophthalmology,  otology,  laryngology,  gynecology,  andrology  and 
urology,  or  whatever  of  it  belongs  to  the  preceding  two  cate- 
gories, are  subtracted  ?  Or  shall  we  still  further  diminish  its  field 
by  eliminating  neurology,  psychiatry,  pediatrics  and  dermatology? 
The  position  of  the  dermatologist  calls  for  especial  consideration. 
It  is  conceded  that  surgery  does  not  claim  him.  If  we  follow  the 
Vienna  school  in  assuming  that  the  skin  is  an  organ,  as  the  eye 
or  the  ear,  he  would  be  an  exponent  of  one  of  the  narrower  fields 
of  specialism.  If  we  should  adhere  to  the  tenets  of  the  London 
school  and  expect  the  attention  to  be  directed  to  the  study  of  sys- 
temic conditions,  which  that  school  has  emphasized,  he  could  read- 
ily be  enrolled  as  a  practitioner  of  internal  medicine.  In  fact,  one 
of  the  greatest  names  of  that  department  of  the  healing  art  was 
Hutchinson,  whose  fame  rests  largely  upon  a  disease,  syphilis,  which 
is  clearly  in  the  field  of  internal  medicine.  If  we  are  influenced 
by  the  Paris  school,  our  decision  must  rest  somewhat  in  doubt. 
However,  this  is  a  question  upon  which  the  Congress  eventually 
must  take  official  action.  A  definition  which  is  predicated  solely 
upon  exclusion  is  neither  logical  nor  final.  The  schismatic  opera- 
tions being  repeated,  the  remaining  moiety  might  readily  become 
negligible.  A  definition  must  be  not  only  inclusive,  but  as  well 
exclusive.  We  may  define  the  domain  of  internal  medicine  as 
including : 

1.  Diseases  caused  by  parasites:  Psorospermiasis,  distomiasis, 
trypanosomiasis  and  by  nematodes,  cestodes  and  parasitic  insects 
from  arachnidas  to  pediculi,  either  as  directly  causing  disease  or 
by  their  acting  as  carriers. 

2.  Infectious  diseases,  of  which  enteric  fever,  diphtheria,  infec- 
tious pneumonia,  tuberculosis,  erysipelas,  syphilis  and  the  eruptive 
fevers,  communicable  or  contagious,  represent  various  types.  These 
number  nearly  ninety,  the  majority  of  definite  and  known  causa- 
tion, all  readily  recognizable,  and  all  presenting  pathological  mani- 
festations of  which  the  treatment  must  fall  to  the  lot  of  the 
internist. 

3.  Constitutional  diseases,  such  as  gout,  diabetes,  scurvy,  rickets 
and  others. 

4.  Intoxications,  including  the  various  metallic  poisonings,  alco- 
holism and  other  drug  poisonings,  food  and  occupational  poison- 
ings, and  the  results  of  exposure  to  high  temperatures. 

5.  Diseases  of  the  digestive  system  and  its  adnexa,  the  liver,  and 
pancreas. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        11 

6.  Diseases  of  the  blood  and  of  the  ductless  glands,  which  are 
not  only  of  increasing  interest  and  importance,  but  are  likely,  in 
the  future,  to  necessitate  a  new  classihcation. 

7.  Diseases  of  the  circulatory  system:  heart,  pericardium  and 
blood  vessels. 

8.  Diseases  of  the  respiratory  system,  including  those  of  the 
pleura. 

9.  Diseases  of  the  mediastinum,  few  in  number,  and  relatively 
rare,  but  of  enormous  difficulty  in  diagnosis. 

10.  Diseases  of  the  urinary   system. 

11.  Diseases  of  the  nervous  system,  including  those  of  the  mind. 

12.  Diseases  of  the  muscular  system;  the  myosites,  the  dys- 
trophies and  the  disorders  of  function  of  which  myasthenia,  myo- 
tonia and  paramyoclonus  are  types. 

It  cannot  be  assumed  that  this  classification  is  final,  because  not 
only  are  individual  diseases  constantly  changing  from  one  division 
to  another,  as,  for  instance,  pneumonia  from  diseases  of  the  res- 
piratory system  to  the  infectious  diseases,  but  also  some  groups 
may  be  merged  together  as  our  knowledge  of  etiology  increases. 
The  terrain  will  remain  the  same,  although  the  boundaries  of  the 
different  divisions  may  change. 

This,  then,  is  the  broad  domain  of  internal  medicine ;  which  is 
of  such  eminent  importance  in  the  life-history  of  mankind,  and 
which  dominates  all  the  limited  specialties  of  the  healing  art.  Its 
successful  cultivation  demands  that  all  sciences  render  aid — physics, 
and  its  younger  brother,  physical  chemistry,  botany,  zoology  and 
especially  biology  in  the  broader  acceptation.  Upon  this  advanced 
knowledge  and  the  logical  interpretations  of  it,  and  the  legitimate 
applications  to  that  complex  category  of  physico-chemical  relation- 
ships, which  we  call  life,  must  depend  substantial  and  beneficial 
progress  in  internal  medicine.  In  its  domain  are  to  be  found  the 
greatest  incidence  of  disease,  either  in  number  or  importance  of 
disability  and  the  preponderating  causes  of  death. 

Can  this  field  of  internal  medicine  be  divided?  There  is  no  doubt 
that  in  practice  this  may  be  done  to  a  limited  extent.  For  in- 
stance, diseases  of  the  nervous  system  can  be  separated  from  in- 
ternal medicine  and  the  neurologist  may  confine  his  efforts  to  dis- 
eases of  that  system,  and  further  the  psychiatrist  may  limit  his  prac- 
tice to  the  diseases  of  the  mind,  but  he  will  be  the  more  useful 
alienist  whose  knowledge  of  diseases  of  the  nervous  system  is  the 
greater,  and  both  will  be  more  completely  experts  the  more  accurate 


12       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

and  comprehensive  their  knowledge  of  the  broad  field  of  internal 
medicine  has  become.  The  medical  diseases  of  infancy  and  child- 
hood have  many  exponents  who  properly  confine  their  practice  to 
those  periods,  because  not  only  does  the  physiology  and  pathology 
of  the  constructive  period  of  the  body  dififer  from  that  of  the  adult, 
but  diagnosis  and  treatment  present  variant  problems.  So  also  do 
the  diseases  incident  to  old  age,  but  with  a  solution  hopeless  as 
to  the  final  outcome,  though  fruitful  in  alleviating  many  of  its  dis- 
comforts. In  passing,  attention  might  be  called  to  the  fact  that 
the  time  during  which  the  pediatrist  exercises  his  functions  does 
not  always  end  with  puberty,  but  may  even  extend  itself  through 
that  of  childhood,  which  some  of  our  pedagogues,  notably  college 
presidents,  assume  to  continue  during  the  entire  period  of  education 
which  is  necessary  to  adapt  the  human  being  to  his  environment 
and  to  fit  him  for  his  greatest  usefulness,  and  this  period  has  been 
mentioned  as  thirty  years.  When  we  reflect  that  the  storm  and 
stress  of  modern  civilization  have  shortened  the  span  of  human 
life,  and  men  may  be  octogenarians  in  body,  if  not  mind,  at  sixty 
or  even  earlier,  the  period  of  adult  life  may  become  a  brief  one, 
and  the  pediatrist  and  the  geriatrist  may  almost  meet  in  their  sep- 
arate fields  of  activity.  Thus  it  is  evident  that  both  should  be  thor- 
oughly versed  in  the  domain  of  internal  medicine.  It  is  indeed 
true  that  the  foundation  of  senility  is  laid  in  the  period  of  child- 
hood, and  that  man  usually  begins  to  die  the  moment  that  he  is 
born.  The  laboratory  workers,  whether  in  the  field  of  biological 
chemistry,  bacteriology,  parasitology,  physiological  therapeutics  and 
in  physics,  especially  in  electro-therapeutics  and  rontgenology,  cer- 
tainly have  claim  upon  our  consideration.  To  them  internal  medi- 
cine owes  much,  not  only  in  indicating  new  avenues  of  progress, 
but  as  well  in  scientific  demonstration  of  the  verity  of  what  em- 
pirically we  have  established  as  facts  in  internal  medicine,  and  we 
have  made  but  a  beginning. 

Granting  that  the  foregoing  are  legitimate  subdivisions  of  scien- 
tific endeavor  and  practical  realization  in  the  field  of  internal  med- 
icine, the  question  of  further  limitation  of  practice  immediately  sug- 
gests itself.  The  natural  cleavage  would  be  in  accordance  with 
the  classification  which  has  been  given  at  the  outset,  according  to 
the  different  physiological  systems.  The  diseases  of  the  circulatory 
system  depend  upon  a  distinct  group  of  organs,  but  the  results 
of  imperfect  function  or  structural  disease  are  as  far  reaching  as 
the  circulation  of  the  blood,  and  their  symptomatology  may  be  the 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        13 

symptoms  ascribable  to  any  one,  many,  or  all  of  the  physiological 
systems.  The  worker  in  the  field  of  diseases  of  the  circulatory 
system  may  limit  his  practice,  but  he  will  be  expert  only  as  he  is 
versed  in  internal  medicine.  The  stomach  specialist  per  se  has  no 
reason  for  his  existence.  If  he  devotes  himself  to  diseases  of  the 
digestive  system  and  includes  with  these  the  disorders  of  metabolism 
and  the  constitutional  diseases,  his  field  is  broad  enough  to  occupy 
his  best  endeavors,  but  here  again  he  must  be  conversant  with  the 
established  facts  of  the  larger  territory  occupied  by  internal  med- 
icine if  he  shall  attain  real  usefulness. 

So  might  be  cited  the  group  of  infectious  diseases,  often  pre- 
senting problems  of  diagnosis,  and  the  same  statement  applies  as 
to  the  importance  of  a  broad  and  comprehensive  knowledge  of  in- 
ternal medicine.  Further  than  this,  the  exponent  of  internal  med- 
icine, no  matter  whether  he  shall  be  the  one  considering  the  field 
in  its  entirety,  or  one  limiting  his  work  to  a  subdivision  of  it, 
must  know  syphilis  in  all  its  manifestations,  and  its  results.  For 
its  widely  spread  incidence  must  always  be  taken  into  account  as 
modifying  disease  or  dominating  therapy  throughout  the  whole  field 
of  internal  medicine.  Its  signs  and  symptoms  are  often  so  bizarre 
that  even  its  recognition,  at  times,  is  exceedingly  difficult,  the  Was- 
sermann  reaction  notwithstanding.  The  range  and  scope  of  in- 
ternal medicine  are  well  defined  and  its  domain  is  accurately  marked 
out,  both  inclusively  and  exclusively. 

The  relationship  of  surgery  to  internal  medicine  is  intimate,  and 
yet  the  differentiation  is  apparent.  There  is  hardly  a  disease  in 
the  entire  range  of  internal  medicine  but  that  at  some  time  in  its 
course,  or  in  the  presence  of  some  complication,  surgical  interven- 
tion may  be  called  for.  And  this  intervention  may  be  necessary 
at  an  early  date — in  fact,  so  soon  as  the  diagnosis  can  be  established, 
as,  for  instance,  in  acute  appendicitis.  It  is  well  to  bear  in  mind 
that  what  are  often  denominated  border-line  diseases  are  really 
those  in  which  the  activities  of  the  medical  attention  and  surgical 
practice  are  concurrent.  There  are  others,  for  example,  choleli- 
thiasis, in  which  the  etiology  falls  in  the  domain  of  internal  med- 
icine, the  important  item  of  relief  comes  under  the  jurisdiction  of 
the  surgeon,  while  the  final  cure  comes  within  the  purview  of  in- 
ternal medicine. 

As  internal  medicine  and  its  contributing  laboratory  work  has 
laid  the  foundations  for  real  surgical  advance,  so  internal  medicine 
can  make  surgery  of  its  highest  possible  value.     The  best  surgical 


14        THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

work  done  in  this  country  to-day  is  accomplished  by  intimate  scien- 
tific cooperation  between  the  skilled  exponents  of  internal  medicine 
and  the  expert  operator.  The  mere  operator  may  be  an  agent  of 
destruction,  no  matter  how  deft  he  may  be  or  how  perfect  his  tech- 
nic.  He  only  reaches  his  highest  usefulness  when  he  has  a  broad 
knowledge  of  internal  medicine ;  that  is,  becomes  a  surgeon,  or  re- 
lies upon  other  experts  for  diagnosis  and  an  analysis  of  the  real 
condition  of  the  organs  and  functions  of  the  patient.  Naturally, 
this  statement  does  not  apply  in  its  entirety  to  operations  of  urgency. 
When  the  surgeon  attempts  to  be  a  general  practitioner  we  are 
likely  to  be  informed  as  to  the  surgery  of  dyspepsia  or  the  abla- 
tion of  a  function.  Medical  surgery  is  not  likely  to  yield  the  best 
results  and  surgical  medicine  is  sure  to  be  disappointing. 

The  relationship  of  internal  medicine  to  surgery  is  fundamental 
and  necessary — this  fact  must  be  recognized  by  the  practitioners  of 
both — but  it  must  be  founded  on  mutual  confidence  and  respect 
for  technical  skill.  Although  internal  medicine  dominates  the  sit- 
uation, it  does  not  detract  from  a  just  admiration  for  the  wonder- 
ful results  which  modern  surgery  has  accomplished.  The  mechan- 
ical skill  and  the  perfect  technic  of  the  operator  are  rewarded  by 
appreciation,  but  the  intellectual  work  of  the  trained  exponent  of 
internal  medicine  is  equally  worthy  of  admiration. 

We  have  defined  the  field  of  internal  medicine  and  have  shown 
its  relationship  to  the  coordinate  branch  of  the  healing  art — surgery 
— and  the  narrow  specialties,  and  now  we  must  define  our  name. 
It  is  a  curious  fact  that  the  practitioners  of  internal  medicine  have 
not  yet,  by  common  consent,  so  far  as  this  country  is  concerned, 
received  a  distinctive  name.  The  term  "diagnostician"  has  been 
suggested.  Diagnosticians  we  certainly  are,  and  we  are  proud  to 
be  considered  as  such,  but  we  realize,  better  probably  than  any 
other  group  of  practitioners,  that  diagnosis  is  not  the  svim  total 
of  our  efforts,  but  only  the  conclusion  of  the  first  stage  of  our 
work,  and  merely  preliminary  to  the  part  that  is  most  important 
to  our  patients,  which  is  treatment.  We  certainly  are  not  general 
practitioners,  either  in  theory  or  practice.  For,  with  the  mass  of 
accumulated  facts  and  the  logical  deductions  therefrom,  neither  the 
learning  of  an  Aristotle  nor  the  intellect  of  a  Bacon,  nor  both 
combined,  if  such  a  genius  were  possible,  could  result  in  so  broad 
a  knowledge,  so  vast  an  experience,  and  so  great  a  technical  skill 
that  all  phases  of  scientific  endeavor  could  be  marked  with  such  a 
degree  of  usefulness  as  we  believe  adequate  for  professional  work. 


THE  AMERICAN  COXGRESS  OX  IXTERXAI.  MEDICINE        15 

Nor  does  this  statement  conflict  with  the  opinion  that  speciahsts, 
both  broad  and  narrow,  are  better  speciahsts  if  the  earher  years  of 
their  career  are  devoted  to  general  practice,  and  the  broader  their 
knowledge  and  the  larger  their  experience  in  the  general  field  the 
more  likely  are  they  to  become  really  expert  in  the  smaller  field 
to  which  their  natural  aptitude  or  especial  opportunities  may  have 
limited  them.  The  name  "internist"  is  undoubtedly  the  proper  one 
for  those  whose  activities  are  circumscribed  by  the  limits  which 
have  been  set  down  earlier  in  this  address.  The  term  "physician" 
too  often  is  assumed  to  have  the  qualifying  adjective  "general" 
omitted,  and  is  not  distinctive.  In  the  profession,  even,  one  who 
has  worked  exclusively  in  the  field  of  internal  medicine  for  a  quar- 
ter of  a  century,  eschewing  surgery,  obstetrics  and  the  narrower 
specialties,  who  has  been  a  teacher  of  medicine  and  an  author  of 
text-books  upon  its  practice,  is  frequently  and  erroneously  desig- 
nated as  a  "general  practitioner."  In  Great  Britain  we  are  known 
as  "internists" ;  on  the  Continent  "internal  medicine"  is  recognized  ; 
let  us  be  known  in  this  country  as  internists,  and  be  willing  to  de- 
fine the  term  until  such  time  as  the  profession  and  the  people  know 
what  it  means,  and  medical  associations,  big  and  little,  represent- 
ing or  not  medical  science,  afford  the  designation  official  recog- 
nition. We  must  teach  that  the  "internist"  is  an  educated  and 
trained  physician,  who  gives  his  best  endeavors  to  an  accurately 
delimited  field,  known  as  "internal  medicine,"  and  that  the  real 
internist  is  not  only  a  specialist,  but,  what  is  far  more  rare,  an 
expert.  It  is  to  the  internist  that  the  heritage  of  the  earlier  physi- 
cians has  come.  This  is  the  American  Congress  on  Internal  Med- 
icine, and  we  are  the  descendants  of  men  who  have  served  their 
time  and  generation,  and  have  left  their  impress  upon  American 
medicine. 

We  probably  recall  John  Morgan  (b.  1736),  of  Philadelphia,  pio- 
neer with  William  Shippen,  Jr.  (b.  1736),  in  the  establishment  of 
a  school  for  medical  education,  the  grandfather  of  American  med- 
icine, and  Samuel  Bard  (b.  1742),  of  New  York,  who  was  iden- 
tified with  the  earliest  medical  instruction  in  this  city.  Probably 
the  best  known  name  of  this  generation,  but  whose  activities  were 
so  varied  that  he  is  better  known  in  connection  with  the  revo- 
lutionary period,  was  the  Father  of  American  Medicine,  Benjamin 
Rush  (b.  1745),  of  Philadelphia;  his  third  edition  of  "Medical  In- 
quiries and  Observations  Upon  the  Diseases  of  the  Mind"  (his  first 
was  in  1812)   lies  before  me  bearing  the  date  1827.     It  is  inter- 


16       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

esting,  if  not  instructive,  and  is  written  in  idiomatic  and  classical 
English  well  worthy  of  Addison,  and  it  is  a  model  for  the  medical 
editor  of  today. 

Another  worthy  of  this  period  was  Nathan  Smith  (b.  1762), 
who  at  Dartmouth  did  not  occupy  a  professional  chair,  but  rather 
an  entire  settee,  for  he  taught  medicine,  surgery,  anatomy,  therapeu- 
tics, botany,  physiology  and  chemistry.  A  contemporary  of  Daniel 
Webster,  although  there  was  twenty  years  difference  in  their  ages, 
he  contributed  much  to  medical  science,  as  well  as  established  two 
medical  schools.  In  1813  he  came  to  New  Haven  and  repeated  his 
pioneer  work  in  founding  the  medical  school  which  subsequently 
became  a  part  of  Yale.  He  died  in  1829,  and  his  grave  in  the 
Grove  Street  cemetery  is  still  a  Mecca  for  medical  men.  As  pro- 
fessor of  the  theory  and  practice  of  physics  and  surgery,  his  name 
is  upon  my  grandfather's  diploma,  in  1819. 

The  fourth  to  establish  medical  schools  was  Benjamin  Water- 
house,  the  physician,  who  with  John  Warren  (b.  1753),  made 
possible  a  medical  school  in  connection  with  Harvard,  in  1782.  He 
also  was  the  first  to  introduce  Jennerian  vaccination  into  this  coun- 
try, which  he  did  in  1800.  In  all  the  early  efforts  to  establish 
medical  instruction  in  this  country,  the  medical  aspect  of  the  heal- 
ing art  looms  large. 

The  son  of  Nathan  Smith,  Nathan  R.  Smith,  in  1825  published 
his  "Physiological  Essay  on  Digestion,"  which  antedated  much  that 
was  subsequently  discovered.  My  copy  from  my  grandfather's  li- 
brary bears  upon  its  title  page  this  sentence :  "It  is  no  small  part 
of  science  to  be  well  acquainted  with  its  real  boundaries ;  but  it 
is  necessary  also  to  know  what  it  is  which  truly  exists  within  these 
boundaries,  and  what  it  is  which  is  only  fabled  to  exist."  A  little 
later  than  this  time  we  recall  William  Beaumont  (b.  1784),  pioneer 
physiologist  of  this  country,  whose  experiments  and  observations 
on  the  "Gastric  Juice  and  Physiology  of  Digestion,"  Plattsburg, 
1833,  were  epoch  making.  Curiously  enough,  the  place  of  his  ob- 
servations upon  Alexis  St.  Martin  was  the  battlefield  of  1814,  a 
portion  of  which  is  now  occupied  by  the  Military  Training  Camp, 
with  which  you  are  all  familiar. 

Passing  by  many  contemporary  lesser  lights,  we  come  to  another 
epoch-making  medical  advance.  While  we  may  speak  of  the  work 
of  Crawford  W.  Long  and  his  rival  claimants  to  priority,  Jackson, 
Wells  and  Marcy,  this  fact  is  firmly  established :  It  was  William 
T.  G.  Morton   (b.   1819)   who  first  publicly  demonstrated  that  by 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        17 

the  inhalation  of  ether  unconsciousness  sufficiently  profound  to  per- 
mit of  surgical  interference  could  be  produced  by  medical  means. 
This  was  on  October  i6,  1846;  the  place  was  the  Massachusetts 
General  Hospital,  and  there  are  those  present  in  this  room  who 
have  heard  the  narration  of  that  event  from  the  lips  of  those  pres- 
ent at  the  demonstration.  It  was  also  another  graduate  of  Har- 
vard, Oliver  Wendell  Holmes,  in  his  early  days  a  physician,  but 
better  known  as  an  author  of  delightful  fiction,  both  prose  and 
poetry,  and  a  teacher  of  anatomy,  who  coined  the  word  "anes- 
thesia," by  which  this  priceless  boon  to  humanity  is  known  through- 
out the  whole  world. 

Medicine  has  made  modern  surgery  possible,  and  to  it  credit 
must  be  given  for  the  wonderful  surgical  work  that  is  being  done 
today.  Parenthetically  it  might  be  remarked  that  anesthesia  has 
also  permitted  some  very  mediocre  surgery — thus  not  every  great 
blessing  is  entirely  unalloyed. 

Fundamental,  also,  to  the  present  value  of  surgery  is  antisepsis, 
which  has  been  developed  as  purely  a  medical  problem,  and  which 
has  led  to  asepsis  as  an  ideal  of  more  or  less  complete  realization, 
although  the  present  European  conflict  which  is  now  raging  has 
demonstrated  that  chemical  antisepsis  is  still  of  great  importance. 

An  epoch-making  book  of  a  later  date  was  "Nature  in  Disease," 
by  Jacob  Bigelow  (b.  1787),  a  Harvard  professor;  my  copy,  the 
second  edition,  bears  the  date  of  1859,  although  the  first  was  pub- 
lished in  1854.  His  views  on  self-limited  diseases  directed  rigid 
analysis  of  the  value  of  therapeutic  measures.  In  his  dedication  of 
it  to  Robley  Dunglison  (b.  1798),  the  medical  lexicographer  and 
another  of  our  medical  Nestors,  we  find:  "I  am  sure  that  you 
will  unite  with  me  in  admitting  that  the  experience  of  a  long 
professional  Hfe  is  the  best  corrective  of  the  exaggerated  estimate 
which  we  are  liable  to  form,  or  imbibe,  in  our  earlier  years,  as 
to  the  power  of  medication  to  control  disease."  Dunglison  also 
occupied  a  settee  at  the  University  of  Maryland,  for  he  was  pro- 
fessor of  materia  medica,  therapeutics,  hygiene  and  medical  juris- 
prudence, and  his  writings  comprised  systematic  treatises  upon 
"Physiology,"  "Hygiene,"  "Therapeutics,"  "Practice"  and  "Materia 
Medica." 

W.  W.  Gerhard  (b.  1809),  of  Philadelphia,  must  claim  our  atten- 
tion for  a  moment,  for  he  was  the  "first  man  to  distinguish  clearly 
the  difference  between  typhus  and  typhoid  fevers." 

Of  the  more  recent  developments  in  medical  science  due  to  Amer- 


18        THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

lean  medicine  we  need  only  to  allude  to  our  antityphoid  vaccine, 
the  most  efficient  of  any  country,  to  our  work  on  uncinariasis, 
yellow-fever,  pellagra  and  malaria,  to  our  work  on  sanitation  in 
tropical  and  subtropical  countries,  which  has  given  such  brilliant 
results,  the  names  of  those  who  have  made  medical  history  arc 
upon  our  lips,  some  are  yet  living — others,  alas,  have  fallen,  mar- 
tyrs to  medical  science. 

The  greatest  triumphs  over  diseases,  and  even  death,  achieved 
during  the  last  half  century  have  been  medical  rather  than  surgi- 
cal. They  have  been  the  discovery  of  the  causa  causans  of  disease, 
and  the  separation  of  the  infections,  due  to  bacteria,  or  protozoa 
or  other  organisms  of  the  lower  zoological  orders,  from  the  in- 
flammations and  degenerations.  The  direct  result  of  our  knowl- 
edge of  etiology  has  resulted  in  the  preventing  of  the  incidence  of 
disease  on  the  one  hand,  by  intelligent  hygiene,  and  by  extensions 
of  the  theory  of  Jennerian  vaccination  to  other  diseases,  notably 
diphtheria,  tetanus  and  enteric  fever.  And  a  further  direct  result 
has  been  the  ability  to  cure  such  infections  during  brief  periods, 
as  has  been  particularly  demonstrated  in  diphtheria,  malaria  and 
syphilis,  and  not  only  this,  but  as  well,  by  serological  methods,  to 
demonstrate  that  the  cure  is  absolute  and  permanent.  In  others, 
as  acute  rheumatic  polyarthritis,  we  have  found  methods  to  mark- 
edly shorten  its  duration,  directly  alleviate  suffering,  and  prevent 
frequent  complications. 

Among  the  constitutional  diseases  absolute  prevention  and  rela- 
tive cure  has  been  brought  about  in  some,  for  example,  in  scorbu- 
tus, diabetes  and  gout,  with  a  minimizing  of  suffering  in  some 
and  averting  a  fatal  issue  in  others.  In  diseases  of  the  circulatory 
system  medicine  has  made  startling  advances  in  drug  therapy  and 
physical  procedures,  so  that  no  longer  are  the  problems  approached 
with  other  than  confident  expectation  of  benefit  and  relative  cure 
so  long  as  degenerations  can  be  checked  in  their  course  and  struc- 
tural changes  have  not  extended  beyond  the  possibility  of  func- 
tional recovery.  The  same  may  be  said  of  the  diseases  of  the 
respiratory,  digestive  and  urinary  systems.  Among  the  great  tri- 
umphs of  recent  medicine  may  be  cited  the  accurate  and  produc- 
tive studies  upon  the  blood,  and  work  upon  the  functions  of  the 
ductless  glands,  the  results  of  which  have  been  far  reaching  and 
of  inestimable  value,  and  whose  importance  in  health  and  disease 
cannot  be  overestimated.  I  need  not  remind  you  that  these  prob- 
lems are  purely  the  problems  of  internal  medicine,  and  their  solu- 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        19 

tion  depends  solely  upon  the  internist.  In  fine,  the  most  impor- 
tant developments  in  the  healing  art,  important  not  only  in  the 
larger  number  of  diseases  and  of  major  importance,  but  as  well 
in  the  larger  number  of  individuals  afflicted,  has  been  in  the  domain 
of  internal  medicine.  And,  furthermore,  the  greatest  progress  in 
the  immediate  future  must  of  necessity  be  in  this  very  field. 

The  record  of  the  distinguished  physicians,  our  medical  ances- 
tors, is  far  too  long  to  be  adequately  presented  in  a  ponderous  tome, 
let  alone  in  an  address.  They  were  giants  in  those  days,  of  thor- 
ough mental  training  and  discipline,  of  accurate  and  painstaking 
observation,  of  rigid  logical  analysis  and  productive  clinical  de- 
ductions. They  have  contributed  in  large  measure  to  the  advance 
of  medical  science  and  therapeutic  art.  We  are  the  legatees  of 
these  physicians  of  a  magnificent  medical  past,  and  as  internists  we 
are  the  trustees  of  the  glorious  internal  medicine  of  the  future, 
whose  soundness  in  scientific  basis,  whose  development  in  the  allevi- 
ation of  suffering  and  the  prevention  and  cure  of  disease,  and 
whose  value  to  suffering  humanity  only  the  seer  must  venture  to 
predict.  This  is  the  function  of  the  Congress  on  Internal  Medi- 
cine ;  to  view  with  reverence  the  foundations  laid  down,  broad  and 
deep  by  the  physicians,  our  medical  ancestors,  and  as  internists  to 
raise  upon  them  a  useful  structure  for  the  healing  of  the  nations. 

The  Congress  on  Internal  Medicine  has  for  its  raison  d'etre  (i) 
to  define  its  domain,  (2)  to  procure  recognition  of  the  designation 
"internists,"  (3)  to  promote  solidarity  of  the  interest  and  achieve- 
ment among  them  and  (4),  finally  and  most  important,  to  advance 
the  science  of  biological  medicine,  of  which  we  are  the  exponents : 
(a)  by  the  selection  of  experts  who  shall  report  the  results  of 
their  investigations  of  important  problems  and  of  intensive  clinical 
study  and  experience,  (b)  by  extending  the  sphere  of  influence  of 
the  constructive  workers  in  internal  medicine  through  publication 
of  their  conclusions,  (c)  by  authoritatively  instructing  the  public 
in  regard  to  the  great  problems  of  health  through  the  official  de- 
partments and  services  now  organized,  and  thus  render  them  more 
efficient. 

I  do  not  approach  this  constructive  work  of  building  up  the 
American  Congress  on  Internal  Medicine  with  any  misgivings  as 
to  the  result,  even  when  one  considers  the  ambitious  programme 
which  is  outlined. 

We  believe  that  the  time  has  come  when  the  internists  shall  be 
united  for  scientific  advancement,  and  for  the  benefit  of  suffering 


20       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

humanity,  and  that  this  organization  shall  be  controlled  by  those 
who  have  been  instrumental  in  developing  internal  medicine  by 
modern  scientific  methods,  and  that  this  does  not  meet  a  tem- 
porary need  alone,  but  its  existence  and  importance  will  reach  far 
into  the  future.  Of  its  permanent  success  I  have  not  the  slightest 
misgivings. 

The  American  College  of  Physicians,  through  its  council,  admits 
to  its  fellowship,  by  election,  those  recommended  by  the  council  of 
the  American  Congress  on  Internal  Medicine  from  among  its  mem- 
bers. The  membership  in  the  college  is  restricted  to  those  whose 
practice  is  generally  in  the  field  of  internal  medicine  or  especially 
in  the  recognized  departments  of  the  same.  Its  obligations  are 
those  of  a  gentleman  and  a  member  of  a  learned  profession.  It 
has  been  said  that  the  American  College  of  Physicians  creates  an 
aristocracy  among  the  internists.  The  observer  has  discerned  the 
purpose  of  the  founders  of  the  congress  and  of  the  college.  He 
forgets  that  the  graduate  who  has  earned  the  bachelor  of  arts 
degree  has  become  a  member  of  the  aristocracy  of  letters  created 
centuries  ago.  He  also  forgets  that  the  master  of  arts  degree, 
won  after  study  and  examinations,  admits  the  bachelor  of  arts  to 
a  smaller  group  in  that  aristocracy  of  letters.  These  are  honors 
which  mark  attainment  of  the  individual  in  his  progress  toward 
appreciation  of  the  higher  relationships  of  life. 

The  degree  which  represented  the  completion  of  medical  in- 
struction and  the  satisfying  of  tests  of  knowledge  in  the  earliest 
days  of  our  medical  schools  was  that  of  bachelor  of  medicine, 
as  it  is  today  in  some  other  countries.  There  is  a  priori,  no  rea- 
son why  a  bachelor's  degree  should  not  mark  fittingly  the  termi- 
nation of  undergraduate  study  in  medicine,  as  it  does  even  now 
in  the  other  learned  professions  of  law  and  theology.  However, 
in  1771,  six  years  after  its  foundation,  the  University  of  Pennsyl- 
vania returned  for  the  degree  of  doctor  of  medicine  four  men 
who  had  been  graduated  as  bachelors  of  medicine  in  1768.  Ref- 
erence to  the  catalogue  of  graduates  of  Harvard  University  shows 
that  the  bachelor's  degree  only  was  granted  from  1788  until  18 10, 
inclusive.  With  the  granting  of  the  doctorate  of  medicine,  which 
now  became  the  general  practice,  a  higher  degree  in  medicine  be- 
came no  longer  possible.  The  degree  of  doctor  of  science  has  been 
bestowed,  in  recent  years,  upon  doctors  of  medicine  who  have 
achieved  eminence,  although  the  degree  itself  is  not  distinctive. 
However,  medicine  is  a  branch  of  physical  science,  and  something 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        21 

more,  even  if  Bacon  characterized  it  as  the  conjectural.  But  Bacon 
died  in  1626,  so,  presumably,  he  should  be  pardoned  for  his  unfor- 
tunate designation.  So  it  has  come  about  that  distinction  has  been 
sought  in  degrees  properly  pertaining  to  the  other  learned  profes- 
sions, notably  the  degrees  of  doctor  of  laws  and  doctor  of  civil 
law,  although  so  far  as  I  know  the  degree  of  doctor  of  divinity  or 
doctor  of  sacred  theology  has  not  been  granted  for  distinction  in 
medicine  per  se.  Fellowship  in  the  American  College  of  Physi- 
cians has  been  safeguarded,  so  far  as  human  foresight  can  go, 
and  it  is  intended  to  be  reserved  for  doctors  of  medicine  who  have 
achieved  eminence  in  the  field  of  internal  medicine  as  practitioners 
and  consultants,  as  investigators  and  scientists,  and  as  authors  and 
teachers.  It  is  intended  that  fellowship  in  the  American  College 
of  Physicians  shall  mean  that  its  possessor  has  attained  eminence 
in,  and  is  an  authority  upon,  internal  medicine  as  a  whole,  or 
upon  some  of  its  recognized  subdivisions.  To  define  our  mean- 
ing: "No  one  has  reached  a  position  of  conceded  eminence  in  his 
profession  unless  it  is  made  to  appear  that  he  is  deeply  and  broadly 
educated,  that  he  has  made  some  substantial  contribution  to  the 
literature  of  the  medical  profession,  and  that  he  has  been  entirely 
related  to  some  phase  of  medical  practice  for  a  sufficient  time  to 
cause  him  to  be  widely  recognized  by  intelligent  members  of  the 
medical  profession,  as  well  as  by  a  considerable  number  of  people 
who  have  occasion  to  be  interested  in  the  services  which  that  pro- 
fession renders  the  people."  The  phase  which  concerns  the  col- 
lege is  internal  medicine.  "Authority  in  the  medical  profession  is 
not  acquired  through  a  medical  education  that  is  only  ordinary 
and  a  practice  that  is  merely  usual ;  eminence  in  the  profession 
can  be  acquired  only  through  the  assiduous  prosecution  of  med- 
ical practice  for  a  considerable  time,  and  through  some  special 
work,  that  has  laid  the  profession  under  some  obligation  to  the 
practitioner."  Eminence  and  authority,  as  used  in  this  connection, 
must  be  given  a  substantial  and  significant  meaning. 

The  schools  of  medicine  by  their  own  action  created  an  aris- 
tocracy in  medicine  as  distinguished  from  law  and  theology ;  it 
has  now  become  necessary  for  the  internists  to  select  from  among 
their  own  number  those  whom  they  deem  deserving  of  additional 
recognition.  If  this,  with  less  reason,  has  been  found  necessary  for 
the  surgeons,  of  by  no  means  distinguished  scientific  heredity,  how 
much  the  more  imperative  is  it  for  the  internists  that  we  shall 
recoenize   in  a   substantial  manner  those  who   have  accomplished 


21       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

much  in  the  upbuilding  and  the  imparting  of  knowledge  in  the  field 
of  internal  medicine! 

The  Chairman  (Dr.  Bartley)  :  Gentlemen,  it  is  unusual  to 
refer  the  President's  address  to  a  committee,  unless  it  contains 
recommendations.  This  address  will  probably  be  published  and 
will  be  accepted  as  an  authoritative  statement  of  the  objects  and 
aims  of  this  organization. 

I  have  not  consulted  the  President,  but  I  feel  sure  that  he  will 
be  glad  to  hear  any  expressions  of  opinion,  pro  or  con,  with  respect 
to  the  definitions  and  the  grounds  which  he  has  taken  in  his  presi- 
dential address.  Is  there  any  one  who  feels  that  the  definitions  or 
statements  of  the  objects  of  this  organization  should  be  in  any  way 
modified  from  the  statements  given  by  the  President  ?  The  address, 
although  it  has  not  been  completely  submitted  to  the  Council,  in 
the  main  received  the  approval  of  the  Council. 

Dr.  L.  F.  Bishop,  of  New  York:  I  rise  simply  to  commend  the 
magnificent  way  in  which  Dr.  Wilcox  has  put  this  matter  before  us. 

Dr.  John  C.  Hemmeter,  of  Baltimore:  It  is  unusual  to  dis- 
cuss a  presidential  address,  but  it  is  also  unusual  that  the  first 
address  at  a  medical  meeting,  at  its  birth,  should  go  by  without  any 
comment  of  the  members.  I  would  move,  as  the  expression  of  the 
entire  body  assembled — if  there  is  no  criticism — that  they  approve 
of  the  ideas  and  definitions  in  the  address  by  a  rising  vote.  Per- 
sonally, I  wish  to  express  my  admiration  of  its  lofty  ideals  and  its 
very  high  scholarship,  and  the  keen  prophecy  by  which  it  sees  the 
time  maturing  when  the  internists  shall  group  together  and  stand 
shoulder  to  shoulder.  I  move  that  the  meeting  by  a  rising  vote 
express  its  approval  of  the  definitions  and  ideals  of  the  address. 

Dr.  T.  E.  Satterthwaite,  of  New  York,  and  Dr.  Allison 
Hodges,  of  Richmond,  Va.,  seconded  the  motion,  which  was 
carried. 

Dr.  Charles  E.  de  M.  Sajous,  of  Philadelphia:  I  think  that 
as  a  representative  of  the  City  of  Brotherly  Love  here  I  could  hardly 
do  better  than  to  express  on  the  part  of  the  physicians  of  Philadel- 
phia their  appreciation  of  the  efforts  that  are  being  made  now  in 
this  very  connection.     I  think  that  Philadelphia  has  contributed  its 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        23 

share  in  the  Hne  of  internists,  and  of  the  beginners,  as  our  President 
has  well  said ;  and  I  am  sure  that  their  shades  will  welcome  this 
great  step  which  is  at  present  so  greatly  needed.  It  seems  to  me, 
also,  that  the  occasion  is  a  very  fortunate  one,  as  far  as  we  are  con- 
cerned, though  on  a  very  unfortunate  foundation,  in  the  sense  that 
this  war  will  prevent  our  European  colleagues  from  doing  within 
the  next  few  hours  such  work  as  they  have  been  doing.  I  think 
this  is  a  great  opportunity  for  the  United  States  to  assert  its  own 
worth,  its  own  power,  and  I  believe  this  Society  will  do  a  great  deal 
in  that  direction. 

Dr.  W.  B.  Stewart,  of  Atlantic  City,  N.  J. :  It  certainly  is  a 
great  pleasure  to  hear  this  subject  presented  by  a  past  master  of 
internal  medicine,  one  who  is  so  well  known  to  all  of  us,  and  one  to 
whom  we  look  for  authoritative  statement.  I  feel  that  the  expres- 
sions made  by  Dr.  Wilcox  to-day,  defining  the  standards  of  the 
internist,  and  also  the  qualifications  for  membership  in  this  Con- 
gress, as  well  as  in  the  College  of  Physicians,  are  well  made ;  and 
I  am  sure  I  can  so  speak  for  those  members  of  the  State  Medical 
Society  of  New  Jersey  who  represent  internal  medicine.  The 
time  has  come  when  the  internist  needs  to  stand  out  separate  and 
distinct  from  the  mixed  surgeon  or  the  surgeon  alone. 

Dr.  Briggs,  of  Boston,  Mass.  :  I  think  there  are  many  physi- 
cians in  Boston  who  will  be  glad  to  know  that  Dr.  Wilcox  recog- 
nizes Dr.  Morton  as  the  discoverer  of  ether.  The  question  as  to 
who  was  the  discoverer  of  ether  has  been  before  the  medical  socie- 
ties for  a  great  many  years,  as  you  probably  know,  and  the  statue 
to  Anesthesia  in  the  Public  Garden  in  Boston  still  remains  without 
a  name  attached  to  it. 

Dr.  W.  H.  Mercur,  of  Pittsburgh,  Pa.  :  I  am  glad  to  see  that 
the  Pittsburgh  internists  are  represented  here  by  five  members, 
which  ought  to  be,  I  think,  a  good  asurance  that  the  internists 
of  Pittsburgh  appreciate  the  value  of  this  movement.  Personally 
I  am  sure  that  the  other  Pittsburghers  who  are  here  will  share 
with  me  in  the  view  which  I  take  of  the  masterly  character  of 
the  address,  and  particularly  of  the  foresight  which  actuated  its 
writing. 

Dr.  Roussell,  of  Philadelphia:  I  think  it  is  quite  apparent  to 
us  all  that  there  is  a  considerable  difference  between  an  internist 


24        THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

in  the  strict  sense  of  the  word  and  a  general  practitioner.  IMore 
than  that,  I  cannot  feel  that  the  situation  is  really  complimentary 
to  the  American  medical  profession.  I  think  we  are  rather  late 
in  the  formation  of  this  particular  society.  This  specialty  is  dis- 
tinctly recognized  in  France,  in  Germany,  and  indeed,  throughout 
Europe,  and  I  know  of  at  least  one  French  society  that  is  con- 
stituted on  the  lines  that  are  here  indicated.  I  think  that  the  time 
has  come  and  that  everything  is  most  propitious  for  the  forma- 
tion  of   this   particular   society. 

Dr.  Robert  H.  Babcock,  of  Chicago:  I  wish  personally  to 
endorse  the  sentiments  expressed  in  our  President's  address,  and 
I  am  sure  that  in  so  doing  I  express  also  the  hearty  endorsement 
of  the  men  who  come  from  Chicago,  and  who  feel  they  have  been 
honored  by  being  chosen  members  of  this  Congress. 

Dr.  Jacob  Diner,  of  New  York  :  There  is  no  question  in  my 
mind  that  every  one  here  enjoyed  and  appreciated  the  address  of 
Dr.  Wilcox.  There  is  one  regret  in  my  mind,  and  that  is  that 
more  of  the  internists  are  not  here  to  listen  to  that  admirable  ad- 
dress. The  young  men  who  are  entering  medicine  are  always 
deeply  impressed  with  the  spectacular  branch  of  medicine  known 
as  surgery.  Internal  medicine  is  generally  the  stepchild  of  the 
student.  I  hope  that  the  Council  will  see  its  way  clear  to  have 
a  copy  of  this  address  sent  to  every  medical  school,  in  charge 
probably  of  the  professor  or  supervisor,  so  that  it  may  be  read 
to  the  students.  No  better  summary  of  the  history  of  medicine 
in  such  a  brief  space  has  ever  come  to  my  notice  than  that  pre- 
sented by  Dr.  Wilcox,  and  I  hope  that  the  students  of  medicine 
will  be  given  an  opportunity  of  listening,  even  at  second  hand,  to 
this  marvelous  and  magnificent  address. 


'fe' 


The  President  called  on  the  Secretary-General,  Dr.  Heinrich 
Stern,  to  make  his  report,  and  in  introducing  him,  pointed  out  that 
it  was  he  who  was  the  real  founder  of  the  Congress. 


*t>* 


Dr.  Heinrich  Stern  :  Mr.  President,  and  Fellows  of  the  Ameri- 
can Congress  on  Internal  Medicine — It  is  six  years  ago  that  I  started 
to  bring  this  forward,  but  it  is  more  than  fifteen  years  that  I  have 
been  thinking  of  seeing  what  is  now  before  us.  It  was  hard  work, 
because  the  American  public,  that  is  the  physicians,  did  not  even 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        25 

know  what  an  internist  was.  A  few  graduates  from  German 
universities  had  an  inkhng  of  it ;  but  the  entire  science  of  internal 
nie(Hcine  has  really  only  sprung  into  existence  during  the  last 
fifteen  or  twenty  years.  When  I  graduated  there  was  not  such 
a  thing  as  internal  medicine.  Everything  was  taken  along,  and 
we  treated  a  case  without  diagnosis,  mainly,  just  according  to  the 
symptoms,  as  well  as  we  could.  After  I  had  left  college  a  few 
years,  my  two  professors  of  surgery  became  my  two  assistants  in 
medicine.  The  men  who  subscribed  their  names  under  my  diploma 
became  my  assistants  in  medicine.  But  what  internal  medicine  at 
that  time  was  I  had  to  develop  myself,  as  far  as  I  was  concerned. 
It  is  true  we  had  some  of  the  older  German  clinicians  ;  but  the 
German  clinicians  were  cjuite  superficial  at  that  time,  too,  although 
they  went  deeply  into  the  cellular  pathology^ ;  but  cellular  pathology, 
as  you  well  know  to-day,  is  not  everything.  The  laboratory,  espe- 
cially the  chemical  clinical  laboratory,  twenty  years  ago  was  not 
even  thought  of,  and  the  few  men  who  had  a  little  chemical  knowl- 
edge, just  branched  out  as  stomach  specialists,  because  they  knew 
how  to  test  with  certain  papers  for  hydrochloric  acid  and  so  forth  ; 
so  it  came  about  that  the  first  internists  were  really  stomach 
specialists.  A  general  practitioner  was  almost  always  a  man  who 
thought  he  knew  something  about  the  heart.  But  when  I  came 
into  medicine,  the  heart  was  hardly  ever  examined  by  means  of 
the  stethoscope;  or  if  a  stethoscope  was  used  it  was  only  a  very 
poor  excuse  for  one ;  you  did  not  hear  much  more  with  the  stetho- 
scope than  without  it.  That  has  all  changed  in  the  last  twenty, 
in  the  last  fifteen,  years.  We  tried  to  do  better  work,  and  we 
know  now  how  to  do  better  work. 

Coming  down  to  the  present  day,  that  is  to  this  Congress,  we 
were  not  quite  sure  wiiether  we  should  issue  cards  of  invitation  for 
this  week, — you  must  know  that  we  are  afifiliated  now  with  the 
American  Association  for  the  Advancement  of  Science,  and  they 
meet  here  in  the  City  of  New  York  at  this  present  time — or  whether 
we  should  wait  until  April  or  May;  and  we  decided,  five  or  six 
weeks  ago,  that  it  had  better  be  now,  and  we  started  to  send  out 
notices  to  the  profession  that  the  Congress  would  take  place  here. 
We  have  over  three  hundred  members  at  this  present  moment,  and  a 
member  means  a  man  who  has  paid  his  five  dollars ;  not  a  man 
who  merely  makes  an  application,  because  we  have  fifty  or  a 
hundred  more;  but  I  have  received  upwards  of  fifteen  hundred 
letters   from  men   who  have  declared   their  intention  to   join  this 


26        THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

Congress  but  were  prevented  from  doing  it  this  year  because  the 
notice  came  too  shortly  before  the  hohdays. 

The  admirable  address  of  Dr.  Wilcox  told  you  what  we  want 
to  do  in  a  scientific  way.  We  want  to  do  even  more  than  he  has 
said.  We  want  to  publish  a  number  of  scientific  journals ;  whether 
we  shall  do  that  this  coming  year  or  the  year  after,  we  do  not 
know  as  yet.  It  is  more  than  what  Dr.  Wilcox  has  outlined  that 
we  contemplate  doing  in  a  scientific  way.  But  Dr.  Wilcox  has 
somewhat  neglected  to  speak  upon  the  financial  side,  which  really 
ought  to  interest  us.  I  know  we  do  not  come  together  to  discuss 
finances ;  but  finally  all  our  studies  are  aimed  at  producing  a  better 
trained  man,  and  the  better  trained  man  is  the  man  w^ho  has  the 
larger  income,  as  a  general  rule.  Nowadays  we  may  have  a  certain 
case ;  we  make  the  diagnosis,  we  refer  the  case  to  a  surgeon,  if 
surgical  procedure  is  necessary ;  or  a  surgeon  is  called  in,  and  the 
surgeon  performs  an  operation  without  our  knowledge,  very  often 
without  our  consent — very  often.  But  certainly,  we  are  not  the 
participant  in  the  fee.  Now,  I  am  not  going  to  talk  about  division  of 
fees,  because  that  is  at  once  excluded.  We  do  not  want  to  come 
down  to  the  American  College  of  Surgeons,  which  w^as  exclusively 
founded  for  certain  financial  purposes  and  the  eradication  of  cer- 
tain practices  in  a  financial  way.  We  internists  have  never  as  a 
profession  tried  to  get  the  better  of  the  patient — never.  I  do  not 
think  there  is  one  real  internist — I  do  not  speak  of  the  general 
practitioner — but  I  really  do  not  think  there  is  one  genuine  in- 
ternist who  has  stooped  down  to  do  his  patients.  He  must  not  do 
it,  and  it  is  an  understood  factor.  What  I  would  like  to  say  is 
this:  If  I  am  able  to  make  a  certain  diagnosis — for  instance,  I 
say  the  right  kidney  is  affected,  the  left  kidney  is  not  affected ; 
the  condition  warrants  the  removal  of  the  right  kidney ;  I  am 
really  the  man  who  bears  the  responsibility  in  the  case.  The  sur- 
geon is  called  in.  The  surgeon  charges  $500.  The  surgeon  gets 
his  $500.  I  get  my  $25  or  $50.  It  is  very  nice,  but  that  is  not 
equal  compensation.  I  certainly  do  not  want  that  patient  to  pay 
me  more  than  $250.  That  is  enough.  It  is  all  that  it  is  worth.  But 
I  want  him  to  pay  me  $250  and  the  other  man  $250.  The  other 
man  is  only  my  handmaiden.  He  is  nothing  more  than  that.  I 
may  order  him,  or  I  may  not  order  him ;  but  I  ought  to  have 
for  my  diagnosis  and  for  the  responsibility  which  I  bear,  as  much 
of  a  financial  remuneration  as  he  has. 

The  first  publication,  gentlemen,  which  we  ought  to  bring  into 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        27 

the  world,  let  us  call  the  Internist,  if  it  has  to  be,  and  let  us 
advocate  in  this  Journal,  which  may  appear  once  every  second 
month,  or  once  every  third  month,  how  we  can  elevate  our  pro- 
fession. Elevation,  in  the  last  instance,  can  only  be  brought 
about  by  monetary  return.  If  we  do  not  have  the  monetary  return, 
we  cannot  buy  instruments,  we  cannot  have  the  proper  outfit,  we 
cannot  have  the  books,  we  cannot  go  to  the  centers  of  learning, 
of  post-graduate  study.  And  that  is  the  point  where  the  surgeon 
has  the  advantage.  He  collects  the  money.  He  goes  to  post- 
graduate institutions,  and  he  comes  back  with  fresh  knowledge, 
and  he  can  always  be  abreast  of  the  times.  Again,  it  is  really  a 
vicious  circle,  and  you  must  comprehend  it — it  is  a  vicious  circle 
which  permits  the  surgeon  to  go  to  the  city  and  to  study  a  little 
more  than  his  neighbor  and  makes  him  also  the  diagnostician  of 
his  little  town. 

Gentlemen,  I  wish  to  provoke  a  little  discussion  upon  that  point, 
and  if  the  President  deems  it  wise,  I  am  ready  to  answer  all 
(juestions. 

The  President  called  on  the  Treasurer,  Dr.  Augustus  Caille, 
for  his  report. 

The  treasurer  submitted  his  report,  which  was  duly  audited,  and 
by  unanimous  vote  was  accepted  as  read. 

The  President  stated  that  the  report  of  the  Treasurer  had  already 
been  audited  by  a  committee  appointed  by  the  Council  of  the  Con- 
gress, and  ordered  it  to  be  placed  on  file. 

The  President  asked  Dr.  L.  F.  Bishop,  of  New  York,  to  pre- 
pare obituary  notices  of  Dr.  Peter  Brynberg  Porter,  the  late  As- 
sistant Secretary  of  the  Congress,  and  Dr.  Frank  H.  Daniels,  the 
late  Treasurer  of  the  Congress. 

Dr.  Bishop  :  It  is  extremely  sad  at  this  time  to  have  to  present 
obituaries,  and  I  have  not  prepared  any  of  the  usual  statistics  with 
which  you  are  all  familiar ;  but  I  ask  you  to  take  these  two  men 
together  and  consider  them  in  conection  with  their  very  earnest 
backing  of  everything  that  pertained  to  the  welfare  of  the  medical 
profession.  Dr.  Daniels  and  Dr.  Porter,  in  the  most  unselfish 
way  that  I  have  ever  witnessed  in  any  department  of  life,  have 
both  given  their  whole  lives  to  the  medical  profession,  without  any 
ulterior  motives.  We  knew  them  well ;  particularly  Dr.  Porter. 
For  years  he  was  Secretary  of  some  of  our  great  medical  societies. 


28        THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

He  had  a  single  purpose  in  promoting  the  welfare  of  the  medical 
profession.  Dr.  Porter  was  a  true  Bohemian.  Money  meant 
nothing  to  him  whatsoever.  If  he  had  enough  money  for  his 
immediate  needs,  he  never  thought  about  the  future  in  any  way. 
He  lived  in  the  simplest  manner  and  devoted  himself  to  the  pro- 
motion of  medical  societies.  He  was  Secretary  of  our  County 
Medical  Association  and  so  on.  He  gave  his  whole  life  to  the 
medical  profession  with  no  ulterior  motive. 

Dr.  Daniels,  in  the  same  way,  though  more  as  a  practitioner, 
devoted  himself  to  the  profession.  And  having  said  that,  I  cannot 
say  any  more,  no  matter  how  long  I  should  speak.  I  think  we 
ought  to  spread  on  our  minutes  an  appreciation  of  what  these  men 
did  for  medicine,  and  although  they  can  no  longer  go  on  with  the 
work,  we  ought  still  to  give  them  credit  for  what  they  intended  to 
do,  because  they  were  among  the  pioneers  in  this,  what  I  consider, 
a  great  movement. 

The  President:  The  Secretary-General  desires  the  Chair  to 
state  that  the  question  of  a  publication  should  be  considered  at 
this  particular  time  in  order  to  get  the  views  of  the  Congress  upon 
its  expediency  or  upon  its  immediate  necessity.  That  is  a  matter 
which  properly  comes  before  the  Council  for  final  action. 

Does  any  one  desire  to  say  anything? 

Dr.  J.  C.  Hemmeter,  of  Baltimore:  One  of  the  most  impor- 
tant incentives  to  the  life  of  an  Association  is  new  members. 
While  we  will  consider  that  in  the  Council,  the  Council  is  only  a 
very  small  Committee  of  this  assembly.  Therefore  I  take  the 
privilege  to  rise  in  the  larger  meeting  to  express  the  desire  to  the 
Fellows,  individually  and  separately,  that  they  will  exert  their 
personal  influence  to  increase  the  membership  of  this  Association 
at  once.  You  have  been  inspired  by  the  address  and  by  the  ideals 
that  have  actuated  the  foundation  of  this  Association.  Now  the 
backbone  of  an  association  is  large  membership,  and  it  can  only 
be  gotten  by  individual  work.  Printed  things  sent  out  to  members 
all  over  the  country  have  some  effect,  but  not  nearly  the  effect 
that  your  personal  influence  can  produce  when  you  return  to  your 
separate  homes.  I  hope  that  these  brief  remarks  will  act  as  an 
incentive  to  the  members  to  procure  new  Fellows  all  over  our 
country. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        29 

Dr.  Noble  P.  Barnes,  of  Washington,  D.  C.  :  I  have  one  sug- 
gestion that  I  would  have  made  before  if  I  had  not  felt  that  the 
time  had  already  been  taken  up,  and  that  is  to  get  this  address  of 
our  President  into  the  hands  of  every  practitioner  in  the  United 
States.  The  concise,  inspiring  effort  that  he  has  given  us  this 
morning,  if  placed  in  the  hands  of  the  medical  profession,  will 
certainly  boost  the  membership  of  the  Congress.  I  move  that  the 
Council  consider  the  advisability  of  having  this  address  of  the 
President  printed  and  distributed  to  the  medical  profession  of  this 
country  and  Canada. 

The  motion  was  seconded  by  Dr.  J.  C.  Hemmeter,  of  Baltimore, 
and  Dr.  C.  D.  Aaron,  of  Detroit,  and  carried. 

Dr.  Britton  D.  Evans,  of  Greystone,  N.  J.:  I  think  that  a 
rather  promiscuous  distribution  of  an  address  of  this  character 
would  be  a  waste  of  energy,  and  attended  with  an  expense  out  of 
proportion  to  the  results  that  it  might  achieve.  I  would  suggest 
that  it  be  sent  to  the  presidents  and  secretaries  of  various  medical 
societies. 

Dr.  I.  M.  W.  Scott,  of  Schenectady,  N.  Y.  :  I  think  that  this 
address  will  be  an  excellent  educational   force   for  the  profession. 

The  President  :  The  only  other  matter  before  us  is  the  election 
of  officers  for  the  ensuing  year.  The  mode  of  procedure  which  is 
laid  down  in  the  By-Laws  is  that  the  Council  act  as  a  Nominating 
Committee,  and  the  names  as  proposed  by  the  Council  will  be 
given  to  you  by  the  Secretary-General.  When  they  have  been 
given  to  you,  that  does  not  preclude — in  fact,  it  should  encourage — 
nominations  from  the  floor  of  other  names  for  the  different  offices. 

The  following  officers  for  the  coming  year  w^ere  nominated  by 
the  Council,  and  were  unanimously  elected: 

President,  Dr.  Reynold  W^ebb  Wilcox  of  New  York. 
Vice  President,  Dr.  Elias  H.  Bartley  of  Brooklyn. 
Secretary-General,  Dr.  Heinrich  Stern  of  New  York. 
Treasurer,  Dr.  Augustus  Caille  of  New  York. 

Five  members  of  the  Council,  of  the  Class  of  1912:  Dr.  J.  Kauf- 
man of   New  York;   Dr.   C.   H.  Jennings  of   Detroit;   Dr.  Judson 


30       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

Daland  of  Philadelphia ;  Dr.  Francis  X.  Dercum  of  Philadelphia, 
and  Dr.  H.  A.  Fairbairn  of  Brooklyn. 

The  President  anounced  that  the  Secretary-General  holds  over 
in  office,  having  been  elected  for  five  years,  according  to  the  By- 
Laws. 

The  Secretary-General  announced  his  appointment  of  Dr.  Joseph 
H.  Byrne  of  New  York  as  assistant  secretary  for  the  ensuing  year. 


THE   DUCTLESS  GLANDS   IN   CARDIO-VASCULAR   DIS- 
EASES AND  DEMENTIA  PRECOX 

By  CHARLES  E.  de  M.  SAJOUS 
Philadelphia 

It  is  precisely  fourteen  years  ago  since  I  signed  the  Preface — the 
portion  usually  written  last — of  a  work  on  the  internal  secretions. 
Curiously  enough,  no  one  seemed  to  realize  at  the  time,  although  its 
title  included  the  suggestive  words  "Principles  of  Medicine,"  the 
underlying  truth  that  it  was  sought  to  convey.  This  truth,  to  me  at 
least,  appeared  to  outstrip  immeasurably,  in  importance,  that  of 
organotherapy,  irrespective  of  any  predominating  position  this 
branch  of  therapeutics  might  ultimately  attain  even  when  the  prod- 
ucts are  become  something  better  than  they  are  now — mere  extracts 
of  the  factory  which  produces  the  secretions  and  not  the  secretions 
themselves.  Swale  Vincent,  however,  summarized  clearly  and  suc- 
cinctly described  my  aims  when  he  wrote  in  1913:  "Sajous  ap- 
parently postulates  a  relationship  between  all  the  ductless  glands 
whose  functions  dominate  most  of  the  bodily  activities,  normal  and 
pathological,  according  to  this  writer." 

Time  has  shown  that  wherever  the  field  has  been  sufficiently  scru- 
tinized, and  some  degree  of  order  introduced  in  the  clinical  or  ex- 
perimental data  collected,  there  was  good  ground  for  the  urgent 
appeal  made  many  years  ago.  I  then  compared  medicine  to  "a  chain 
in  which  the  majority  of  links  were  of  gold  and  the  rest  of  lead 
pending  the  acqusition  of  sufficient  gold  to  replace  the  lead,"  urging 
that  the  ductless  glands  furnished  these  links.  If  I  am  not  mis- 
taken, this  trend  of  thought  is  increasingly  proving  its  soundness, 
and  I  would  be  untrue  to  my  own  convictions  and  perhaps  delay 
progress  in  the  noblest  of  human  endeavors,  did  I  now  hesitate  to 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        31 

assert  with  all  the  emphasis  of  which  I  am  capable,  that  medical 
progress  tvhich  would  require  fifty  years  under  present  conditions, 
would  accrue  in  probably  less  than  ten  years,  if  the  major  ductless 
glands  were  given  due  importance  in  the  pathogenesis  of  all  diseases. 

A  warning  is  necessary  at  the  present  time,  however,  to  avoid 
wrecking  the  ship  while  it  is  being  launched.  One  of  our  most 
distinguished  surgeons,  Professor  W.  S.  Halsted,  of  Johns  Hopkins 
University,  a  most  painstaking  and  conscientious  observer,  wrote 
only  last  year  (1915)  :  "It  must  be  evident  to  everyone,  that  there 
reigns  the  greatest  confusion  on  the  subject  of  the  functions  of  the 
glands  of  internal  secretion."  The  cause  of  this  is  not  difficult  to 
find.  He  relied  mainly  for  his  knowledge  of  these  functions  upon 
the  teachings  of  physiologists,  the  normal  mentors  of  this  phase  of 
medical  thought.  We  all  know  the  enormous  value  of  their  con- 
tributions ot  our  knowledge ;  indeed,  the  names  of  Claude  Bernard, 
Brown-Sequard,  Moritz  SchifT  and  other  physiologists  have  been 
epoch  builders,  and  at  the  present  time  their  labors  are  constantly 
studding  our  knowledge  of  the  ductless  glands  with  new  gifts.  Yet, 
gentlemen,  we  should  not  lose  sight  of  the  fact  that,  precious  as 
their  labors  are  to  us,  their  aims  are  different ;  they  are  first  of  all 
biological  physicists  and  chemists,  we  are  first  of  all  humanitarians. 
Indeed,  as  stated  by  Dr.  L.  Faugeres  Bishop  in  his  work  on  Arterio- 
sclerosis :  "Sick  humanity  is  clamouring  for  relief  and  will  not  wait 
for  the  technicians  slowly  to  complete  their  tasks  and,  in  due  time, 
bear  their  treasures  of  knowledge  and  present  them  for  use.  The 
sick  man  says,  'Go  seize  the  precious  truth  and  use  it  now.'  "  To 
this  I  would  add:  Neither  does  Death  await  the  laboratory  man's 
results,  precious  as  they  are  as  auxiliaries  to  our  labors. 

Our  traditions,  gentlemen,  warrant  not  only  a  bold  effort  to  cor- 
rect a  situation  which  tends  to  perpetuate  the  death-dealing  trend 
of  many  diseases  that  still  defeat  all  our  efforts,  but  they  bid  us  to 
proceed  with  certainty  of  success.  You  will  probably  recall  that 
when  that  eminent  physiologist  Professor  Pawlow  published  his 
work  on  the  digestive  glands,  he  credited  physicians  with  the  dis- 
covery of  their  secretory  innervation  long  before  this  was  done  by 
physiologists.  "They  had  even  come,"  he  wrote  at  the  time,  refer- 
ring to  physicians,  "to  recognize  different  morbid  conditions  of  the 
innervation  apparatus.  Physiologists,  on  the  other  hand,  had  fruit- 
lessly endeavored  for  decades  to  arrive  at  definite  results  upon  the 
questions.  This  is  a  striking,  but  by  no  means  isolated  instance 
where  the  physician  gives  a  more  correct  verdict  concerning  physio- 


32       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

logical  processes  than  the  physiologist  himself."  Then,  to  account 
for  this  oft'  noticed  greater  insight  into  physiological  truths,  he  says: 
"Nor  is  it  indeed  strange.  The  world  of  pathological  phenomena 
is  nothing  but  an  endless  series  of  the  most  different  and  unusual 
combinations  of  physiological  occurrences  which  never  make  their 
appearance  in  the  normal  course  of  life.  It  is  a  series  of  physio- 
logical experiments  which  nature  and  life  institute,  often  with  such 
interlinking  of  events  as  could  never  enter  into  the  mind  of  the 
present  day  physiologist,  and  which  could  scarcely  be  called  into 
existence  by  means  of  the  technical  resources  at  his  command. 
Clinical  observation  will  consequently  always  remain  a  rich  mine  of 
physiological  facts." 

This  should  not  in  the  least  curtail  our  use  of  any  data  physi- 
ologists may  afiford.  They  should,  in  fact,  be  deemed  invaluable 
contributions  to  our  sum  of  evidence,  but  what  I  would  urge  is  that 
we  should  cease  to  depend  totally  upon  their  Jabors  for  the  discovery 
or  elucidation  of  functions  which  are  of  paramount  importance  in 
the  development  of  our  knowledge  of  disease  and  therapeutics.  All 
branches  of  biological  science,  normal  and  morbid,  are  legitimate 
fields  of  investigation  for  elucidative  data,  but  with  clinical  medicine 
as  starting  point  owing  to  the  vast  wealth  of  material  it  affords. 

The  cardio-vascular  diseases  and  dementia  precox  have  been 
selected  to  illustrate  what  the  ductless  glands  might  mean  to  the 
field  of  clinical  medicine.  No  question  seems  to  me  more  worthy 
of  your  attention. 

The  mortality  statistics  of  the  recently  published  Census  for  1914, 
refers  to  the  deaths  from  organic  diseases  of  the  heart  as  "the 
largest  number  classified  under  any  one  of  the  titles  of  the  Interna- 
tional List  of  Causes  of  Death  for  that  year."  It  states,  further- 
more, that  deaths  from  this  cause  "exceeded  the  number  charged 
to  tuberculosis  of  the  lungs  by  more  than  9,000  and  the  number 
assigned  to  pneumonia  (all  forms)  by  nearly  10,000."  Turning 
to  what  the  Census  terms  the  "diseases  of  the  arteries,  atheroma, 
aneurism,  etc.,"  the  figures  given  as  annual  average  for  the  years 
1906  to  1910,  are  considerably  more  than  twice  those  for  1901  to 
1905.  Making  all  allowances  for  the  many  misleading  features 
which  such  statistics  may  include,  the  fact  remains  that  diseases  of 
the  cardiovascular  system  are  increasing  at  a  very  rapid  rate.  It 
might  be  urged  that  comparisons  with  pulmonary  tuberculosis  and 
pneumonia,  such  as  those  submitted  by  the  Bureau,  fail  to  afford 
a  true  idea  of  the  relative  values,  since  both  of  these  diseases  may 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        2>2, 

have  shown  a  decrease  of  mortahty  through  the  improved  prophy- 
laxis and  thrapeutics  of  recent  years.  While  this  criticism  is  war- 
ranted, the  mortality  of  both  pulmonary  tuberculosis  and  pneumonia 
showing  a  very  marked  decline,  the  fact  remains  that  the  actual 
average  of  both  vascular  and  cardiac  diseases  of  recent  years  as 
compared  to  those  of  former  years  likewise  show  a  very  marked 
increase.  Facts  tend  to  suggest,  therefore,  that  while  we  have  suc- 
ceeded in  reducing  the  mortality  of  tuberculosis  and  pneumonia,  our 
results  in  cardiovascular  diseases  have  not  been  such  as  to  compen- 
sate for  their  rapid  increase.  Could  our  present  knowledge,  deficient 
as  it  is,  of  the  functions  of  the  ductless  glands,  and  their  role  in 
disease,  throw  any  light  upon  the  problems  as  a  whole  and  suggest 
remedial  measures  capable  perhaps  of  raising  the  standard  of  our 
results?  If  the  intimate  relationship  between  the  ductless  glands 
and  metabolism  are  recalled,  it  would  appear  as  if  this  question  could 
be  answered  in  the  affirmative. 

ARTERIOSCLEROSIS. 

This  disease  has  become  one  of  the  most  active  agents  of  the 
fell  reaper.  The  word  "disease"  is  hardly  applicable  here,  however, 
for  if  we  take  into  account  the  many  complications  it  entails,  car- 
diac, renal,  cerebral,  mental,  locomotor,  etc.,  we  can  well  say  with 
Huchard  that  we  are  dealing  with  a  family  of  diseases.  The  com- 
plexity of  the  problem  is  further  increased  by  the  multiplicity  of  fac- 
tors which  are  known  to  cause  arteriosclerosis.  Thus,  overfeeding 
accounts  for  the  great  majority  of  cases  of  arteriosclerosis  in  the 
well-to-do ;  toxemias,  including  those  due  to  intestinal  toxins,  gout- 
breeding  purin  bases ;  obstructive  renal  disorders ;  continued  and 
excessive  physical  labor;  the  violent  overstraining  of  athletes;  va- 
rious infections,  notably  typhoid  fever,  rheumatism,  tuberculosis, 
syphilis,  malaria,  etc. ;  poisons  such  as  lead,  barium,  etc. ;  stimu- 
lants, alcohol,  tobacco,  tea,  cofifee ;  worry,  anxiety  and  the  general 
stress  of  life, — have  all  been  incriminated  as  causal  factors  of  the 
disease. 

An  effort  to  ascertain  the  status  of  the  ductless  glands  in  the 
pathogenesis  of  the  disease,  should  begin  by  a  full  recognition  of  the 
pioneer  work  done  by  Josue,  of  Paris,  who  produced  vascular  lesions, 
by  injections  of  adrenalin,  resembling  at  least  those  of  arterioscle- 
rosois,  and  who  created  a  syndrome  for  the  early  recognition  of  this 
disease  based  on  the  symptomatology  of  hyperadrenia.  We  shall 
see  that  there  is  good  ground  for  this  attitude  in  certain  cases.    But 


34       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

we  will  find  also  that  other  glands  are  involved  in  the  genesis  of 
the  disease.  To  make  this  clear  I  will  divide  the  morbid  process 
into  three  types. 

Autolytic  Type.  The  pancreas,  from  my  viewpoint,  plays  one  of 
the  leading  parts  in  the  process.  Besides  governing  carbohydrate 
metabolism,  it  supplies  a  ferment  or  ferments  which  take  a  direct 
part  in  the  protein  metabolism  of  the  tissue  cells,  and  also  in  the 
defensive  reactions  within  these  cells,  as  well  as  in  the  phagocytes 
and  in  the  blood  stream. 

In  the  first  edition  of  Internal  Secretions  (1903-1907),  I  sum- 
marized this  feature  of  the  problem  in  the  following  words:  "The 
presence  of  trypsin  and  other  ferments  in  leucocytes  is  now  recog- 
nized as  a  fundamental  feature  of  phagocytosis.  Metchnikofif's 
cytase  is  regarded  by  him,  and  by  Bordet  and  others,  as  a  trypsin ; 
Kanthack  and  Hardy  also  attribute  the  proteolytic  activity  of  leuco- 
cytes to  soluble  ferments.  The  more  recent  writers  refer  increas- 
ingly to  the  presence  in  leucocytes  of  such  a  ferment."  .  .  .  "That 
trypsin  is  the  bactericidal  agent  of  the  intestinal  tract  has  been 
shown  by  Charrin  and  Levaditi,  Zaremba  and  others."  After  a 
study  of  the  trophocytes  of  sponges,  laboratory  studies  of  the  prop- 
erties of  ferments  in  lower  forms,  the  migratory  powers  of  leuco- 
cytes in  higher  forms,  etc.,  I  concluded  that  some  leucocytes  at  least, 
migrated  from  the  intestinal  canal  to  the  tissue  cells,  there  to  carry 
on,  among  other  functions,  that  of  katabolism.  I  also  held  that  in 
the  blood,  besides  acting  as  phagocytes,  they  took  part  in  the  de- 
fensive process  in  the  plasma  when  it  was  invaded  by  bacteria,  tox- 
ins, toxic  waste  products,  or  other  substances  harmful  to  the  tissue 
cells,  the  katabolic  phase  of  metabolism  here  serving  to  break  down 
the  pathogenic  substances,  endogenous  or  exogenous,  precisely  as  it 
did  wornout  components  of  the  tissue  cell. 

Abderhalden  subsequently  (1905-1915)  reached  very  similar  con- 
clusions. "Everything  points,"  writes  this  observer,  "to  the  fact  that 
the  [tissue]  cell  has  agents  at  his  disposal  which  render  it  capable 
of  splitting  up  into  their  simplest  units  all  the  complicated  substances 
which  are  brought  to  it  or  which  it  itself  builds  up."  Again,  "each 
separate  cell  with  very  few  exceptions  disposes  of  the  same  or 
similar  ferments  as  those  secreted  by  the  digestive  glands  in  the 
intestinal  canal."  As  to  the  manner  in  which  the  tissue  cells  are 
reached  by  these  ferments,  he  writes,  "Many  facts  accord  with  the 
suggestion  that  the  leucocytes  play  a  part  in  this  connection."  In 
keeping  with  my  own  views,  Abderhalden  has  termed  the  digestive 


THE  AMERICAN  CONGRESS  ON  INTERN AE  MEDICINE        35 

ferment  a  "defensive  ferment,"  thus  bringing,  lie  adds,  "ilie  so- 
called  reactions  of  immunity  into  close  line  with  i)rocesses  that  are 
normal  and  consequently  familiar  to  the  cells."  Briefly,  the  same 
process  which  prepares  foodstuffs  for  assimilation  and  breaks  them 
down  to  eliminable  wastes,  is  used  by  Nature  to  convert  pathogenic 
substances  likewise  into  eliminable  end-products,  thus  ])rotccting  the 
organism  against  their  morbid  etfects.  This  conception  of  immunity, 
while  devoid  of  complexities,  enables  us  to  understand  clearly  many 
pathological  and  clinical  i)henomcna  that  have  remained  unexplained. 
In  arteriosclerosis,  and  other  conditions  to  which  references  shall 
be  made,  we  witness,  among  other  causative  phenomena,  exaggera- 
tion of  this  digestive  process,  with  tissue  destruction  as  result. 

It  is  not  my  purpose  to  inflict  upon  you  a  mass  of  su])porting  data 
that  have  already  been  published,  but  I  will  recall  that  the  presence 
of  digestive  ferments  in  tissue  cells  has  long  been  recognized.  No 
less  an  authority  than  Vaughan,  in  fact,  states  (1913)  that  "the  cell 
which  can  no  longer  supply  a  digestive  ferment  is  already  dead, 
whatever  be  the  kind  or  amount  of  pabulum  surrounding  it."  As 
regards  the  presence  of  the  digestive  ferment  in  the  blood,  I  may 
quote  Eugene  L.  Opie's  statement  that  "the  ability  of  the  blood  to 
remove  injurious  material  is  dependent  on  the  possession  of  proteo- 
lytic enzymes.  Peculiar  to  the  polynuclear  leucocytes  is  an  enzyme 
which,  like  trypsin,  exerts  its  digestive  action  in  an  alkaline 
medium." 

Wheeler  and  Bishop's  sensitization  theory  of  arteriosclerosis  is 
also  based  on  the  presence  of  trypsin  in  the  tissue  cells,  with  excess 
of  proteins  as  main  pathogenic  agent.  Yet,  how  is  this  sensitizing 
process  carried  on  and  how  are  the  arterial  lesions  provoked?  We 
are  not  dealing  here  with  a  sudden  anaphylactic  reaction,  but  with, 
in  practically  every  instance,  a  very  slow  and  gradual  erosion  as  it 
were  of  the  vascular  walls.  How  is  this  morbid  process  developed? 
This  is  where,  I  believe,  the  functions  of  the  thyroid  and  adrenals 
assert  their  influence, 

While  nothing  proves  that  the  protein  itself  activates  directly  the 
trypsin  zymogen  in  the  cells,  much  evidence  is  available  to  show 
that  it  does  so  indirectly  by  evoking,  in  the  body  at  large,  a  defensive 
reaction.  From  my  viewpoint,  the  protein  does  this  by  enliancing 
the  functions  of  the  thyroid  and  adrenals — beneficially  up  to  a  cer- 
tain limit,  harmfully  zvhen  this  limit  is  exceeded.  In  other  words, 
proteins  used  in  excess  awaken  a  reaction  having  for  its  purpose  to 
convert  the  harmful  surplus  o^  proteins,  both  in  the  cells  and  in  the 


36        THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

blood,  into  eliminable  end-products.  As  long  as  the  excess  is  only 
such  as  to  keep  this  protective  reaction  within  certain  bounds  no 
harm  to  the  tissue  cells  results,  even  though  the  cellular  proferment 
is  sensitized;  but  if,  when  the  protective  tide  is  at  its  highest  level, 
more  proteins  are  added,  the  already  sensitized  cellular  proferment 
becomes  activated,  and  digests  the  cell  itself,  starting  the  destructive 
process,  or  autolysis,  the  precursor  of  arteriosclerosis. 

The  sensitizing  properties  of  the  thyroparathyroid  secretion, 
which  I  assimilated  to  those  attributed  to  opsonin  by  Sir  A.  E. 
Wright  has  been  confirmed  by  others.  Thus  Leopold-Levi  and  H. 
de  Rothschild,  of  Paris,  write  in  this  connection  in  the  second  vol- 
ume of  their  Physiopathology  of  the  Thyroid  Gland:  "Sajous  has 
attributed,  among  the  functions  of  the  thyroid  body,  a  role  to  the 
latter  which  he  assimilates  to  that  of  opsonins  and  to  autoantitox- 
ines.  More  recently,  Miss  Fassin  [at  the  Bacteriological  Institute 
of  Liege],  M.  Stepanoff,  and  M.  Marbe  [at  the  Pasteur  Institute] 
have  confirmed  on  their  side  the  influence  of  the  thyroid  on  the 
blood's  asset  in  alexins  and  opsonins."  For  the  chemical  process 
involved,  which  also  includes  the  cellular  nucleins,  I  must  refer  you 
to  former  writings,  recalling  merely  that  the  high-liver  in  the  earlier 
stages  of  arteriosclerosis  often  presents  symptoms  of  Graves's  dis- 
ease, flushing,  sensation  of  heat,  nervous  irritability,  palpitations, 
high  blood-pressure,  etc.,  and  that  the  thyroid  gland  or  its  prepara- 
tions do  not  always  produce  vaso-dilation,  as  is  generally  taught. 
W.  E.  Waller  has  also  emphasized  this  fact  recently,  citing  a  num- 
ber of  cases  of  Graves's  disease  in  which,  in  keeping  with  some 
of  my  own  observations,  the  blood-pressure  rose  to  170,  and  in  one 
instance  to  250  mm.  In  the  present  calamitous  war  hyperthyroidia 
has  also  been  found  by  L.  T.  Thorne  to  be  accompanied  by  a  rise 
of  blood-pressure.  Autopsies  of  victims  of  Graves's  disease  often 
show,  moreover,  arterial  degeneration  presenting  the  characteristics 
of  arteriosclerosis. 

As  regards  the  production  of  arteriosclerosis  by  adrenal  extrac- 
tives, so  much  evidence  has  been  published  to  that  effect  that  I  will 
only  recall  a  few  facts.  First  observed  by  Josue,  this  phenomenon 
has  been  witnessed  by  many  other  investigators.  Some  authors  have 
argued  that  the  lesions  differed  from  those  of  typical  arteriosclero- 
sis. The  fact  is  that  while  in  some  instances  the  lesions  start  in  the 
intima  and  others  in  the  media,  both  tend  to  merge.  As  regards  the 
influence  of  the  adrenalin  upon  its  genesis,  so  careful  an  observer 
as  Biedl  writes :    "There  is  no  reason  to  doubt  that  the  changes  ob- 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        37 

served  in  the  vessels  of  rabbits  are  the  outcome  of  the  action  of  this 
substance."  Another  close  observer,  Richard  M.  Pearce,  concluded 
after  a  study  of  the  labors  of  Vaquez,  Aubertin  and  Anibard,  Rose, 
Darre,  Landau  and  others,  and  an  examination  of  163  adrenals 
obtained  at  autopsies  of  cases  of  arteriosclerosis,  that  hyperplasia  of 
the  adrenals  was  an  almost  constant  lesion  in  arteriosclerosis  asso- 
ciated with  chronic  interstitial  nephritis  and  left-sided  hypertrophy, 
and  that  it  occurred  with  almost  equal  frequency  in  arteriosclerosis 
with  chronic  nephritis  of  the  parenchymatous  type.  He  also  found 
it  to  be  a  frequent  lesion  of  the  arteriosclerosis  without  nephritis 
and  of  nephritis  without  arteriosclerosis. 

Both  the  thyroid  and  adrenals  being  admittedly  factors  of  the 
problem,  by  what  process  does  a  given  substance,  say  protein  in 
excess,  produce  the  local  morbid  process? 

The  cellular  ferments  are  subject  to  the  laws  of  all  ferments, 
one  of  which  is  that  their  activity  is  increased  by  a  rise  of  tempera- 
ture up  to  a  certain  limit.  This  is  precisely  what  occurs  in  the 
present  connection.  That  the  thyroid  influences  oxidation  is  well 
shown  by  the  studies  of  Magnus-Levy,  Salomon,  Steyrer  and  others, 
in  which  among  other  conclusive  facts,  the  intake  of  oxygen  in 
Graves's  disease  was  found  to  be  increased  from  50  to  80  per  cent. 
As  regards  the  adrenals,  the  progressive  fall  of  temperature  from 
normal  to  80°  F.  or  even  below,  which  follows  their  extirpation, 
the  low  temperature  attending  Addison's  disease,  and  the  fact  that, 
as  stated  by  Biedl,  injections  of  adrenalin  may  cause  a  considerable 
rise  of  temperature,  point  to  the  influence  these  organs  have  on 
general  oxidation — a  process  which  I  regard  as  the  most  important 
of  their  functions.  Finally,  that  the  thyroid  and  adrenals  act  jointly 
and  are  mutually  necessary  is  well  shown  by  the  observation  of 
Eppinger,  Falta  and  Rudinger,  that  adrenalin  fails  to  raise  the  blood- 
pressure  after  the  thyroid  has  been  removed.  All  these  facts  tend 
to  show  that  tJic  increased  temperature  needed  to  activate  the  cellu- 
lar proferment  is  supplied  mainly  through  increased  functional  ac- 
tivity of  the  thyroid  and  adrenals. 

Recalling  the  stimulating  influence  of  overfeeding,  particularly 
of  protein  wastes  on  the  thyroid  and  adrenals,  and  that  the  excessive 
activity  of  these  organs  so  raises  the  sensitiveness  of  the  cellular 
trypsin  that  this  ferment  tends  to  digest  the  very  cells  which  harbor 
it,  through,  as  we  now  see,  increased  oxidation,  we  are  brought  to 
realize  how  typhoid  fever,  scarlatina,  influenza,  rheumatism,  tu- 
berculosis,  and   other    febrile   infections   may    initiate   the   disease. 


38       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

Alcohol  belongs  to  the  same  category  as  a  cause  since,  as  we  all 
know,  it  is  by  undergoing  oxidation  in  the  body  that  it  liberates  its 
energy.  The  cases  due  to  the  excessive  use  of  tobacco  probably 
belong  also  to  this  class,  Cannon,  Aub  and  Binger  having  found 
that  injections  of  nicotine  in  small  amounts  in  cats  caused  an  in- 
crease of  adrenal  secretion.  Gley  likewise  observed  recently  that 
nicotine  caused  an  increase  of  adrenalin  in  the  blood,  while  in  rab- 
bits Leo  Loeb  found  that  the  primary  lesions  caused  by  nicotine 
were  in  the  intima.  An  active  defensive  reaction  such  as  that  oc- 
curring in  gout,  renal  insufficiency,  syphilis,  lead  poisoning,  etc.,  is 
also  attended  by  increased  functional  activity  of  the  ductless  glands. 
As  to  the  pathological  lesions  produced,  the  blood  being  the  active 
oxidizing  agent,  the  lesions  are  those  of  the  nodose  type,  affecting 
first  the  intima,  particularly  where  the  blood  is  most  rich  in  glandu- 
lar products,  the  aorta,  where  autolysis  is  most  active. 

Adrenal  Type.  This  form  is  that  which  approaches  most  nearly 
Josue's  adrenalin  type.  It  dift'ers  from  the  former  or  autolytic  type 
in  that  the  lesions  appear  first  in  the  media.  As  stated  by  Guthrie 
McConnell,  "the  changes  which  develop  do  not  correspond  accu- 
rately with  those  of  the  ordinary  nodose  sclerosis,  but  they  are  in- 
distinguishable from  the  changes  seen  in  IMoenckeberg's  type  of 
medial  degeneration."  Harlow  Brooks  and  Kaplan  reported  an  in- 
teresting case  in  this  connection.  To  relieve  asthma,  the  patient  had 
been  given  intramuscularly  from  lo  to  120  minims  daily  for  over 
three  years.  At  the  autopsy  the  necrotic  foci  were  found  especially 
in  the  media.  As  stated  elsewhere,  the  evidence  tends  to  show  that 
this  form  is  due  to  excessive  constriction  of  the  vasa  vasorum,  owing 
to  the  contracting  influence  of  adrenalin  on  the  smaller  or  terminal 
arteries.  That  the  other  coats  of  the  vessels  may  also  be  involved, 
however,  is  suggested  by  Cowan's  observation  that  while  the  lesions 
in  the  vasa  vasorum  were  sometimes  the  only  visible  ones,  he  had 
observed  cases  in  which  the  interference  with  the  vascular  supply 
from  the  vasal  vessels  produced  medial  and  intimal  necrosis. 

To  this  type  probably  belong  the  numerous  cases  due  to  excessive 
physical  labor — 62  per  cent,  of  3894  hospital  cases  studied  by 
Thayer.  Abelous  and  Langlois,  have  shown  that  the  internal  secre- 
tion of  the  adrenals  destroyed  fatigue  products,  i.e.,  toxic  wastes 
generated  during  muscular  activity.  This  has  been  confirmed  by 
Mosse  and  others.  The  fact  that  emotions,  fear,  etc.,  as  shown  by 
Cannon,  increase  adrenal  activity,  suggests  that  cases  due  to  worry 
and  anxiety,  also  known  to  play  a  part  in  the  etiology  of  the  dis- 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        39 

ease,  belong  to  the  adrenal  type,  though  merged  in  many  instances 
with  the  autolytic  type. 

Dcnutrition  Type.  A  third  type  imposes  itself,  however,  when  we 
take  into  account  the  fact  that  cases  of  myxedema  frequently  show 
postmortem,  advanced  arteriosclerosis  with  typical  lesions  including 
calcification.  A  similar  condition  has  been  observed  by  Bourneville, 
Marchand,  Heyn  and  others,  in  hypothyroidia,  while  premature 
arteriosclerosis  is  not  uncommon  in  diabetics,  particularly  in  the 
advanced  stage.  The  influence  of  the  thyroid  apparatus  upon  oxi- 
dation and  metabolism,  explains  this  phenomenon — diminished  func- 
tional activity,  obviously  defective  metabolism  and  degeneration  in 
the  vessel  walls.  The  sclerosis,  fibrosis,  or  calcification  found  more 
or  less  in  all  forms  being  a  process  of  local  repair,  it  occurs  as  well 
in  this  degenerative  form  as  it  does  in  the  two  preceding.  In  the 
aged,  arteriosclerosis  is  doubtless  due  in  some  instances,  to  deficient 
activity  of  the  ductless  glands.  As  is  well  shown  by  the  studies  of 
Landau,  Ecker,  Heine,  Rolleston  and  others,  the  adrenals,  for  in- 
stance, show  marked  reduction  in  volume  in  wealth  of  vascular 
channels  and  of  secretory  activity,  in  aged  individuals.  This  applies 
also  to  the  thyroid. 

The  fact  that  hypoactive  adrenals  do  not  prevent  the  development 
of  this  denutrition  type  of  arteriosclerosis^  suggests  that  high  blood- 
pressure  is  not  necessarily  a  feature  of  the  morbid  process.  Indeed, 
various  observers  have  brought  on  the  disease  by  injecting  toxics, 
including  adrenalin  with  agents,  amyl  nitrite,  for  instance,  which 
would  prevent  a  rise  of  blood-pressure,  or  in  doses  too  minute  to 
affect  the  latter. 

High  blood-pressure  should  be  regarded,  therefore,  more  in  the 
light  of  a  very  important  early  symptom,  and  also  as  a  valuable 
danger  signal  in  advanced  cases,  than  as  a  causal  factor  of  the 
disease. 

Having  now  submitted  my  conception  of  the  pathogenesis  of  the 
disease,  its  relations  to  diagnosis  and  treatment  may  be  briefly  out- 
lined. 

DIFFERENTIAL    DIAGNOSIS    AND    TREATMENT. 

If  we  would  reduce  materially  the  death-rate  of  arteriosclerosis 
and  its  many  complications,  we  should  as  far  as  possible  learn  to 
establish  clearly  the  symptomatology  of  the  presclerotic  stage,  i.e., 
before  the  bloodvessels  have  become  the  seat  of  lesions,  when  either 
excessive  adrenal  activity,  autolysis  or  arterial  denutrition  is  taking 
place.     The  etiology  here  is,  as  we  have  seen,  of  cardinal  inipor- 


40       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

tance.  As  to  the  symptoms  of  fully  developed  disease,  they  are 
virtually  similar,  being  those  of  arterial  degeneration  however 
caused.  I  will  not  inflict  their  enumeration  upon  you,  and  refer 
only  to  such  remedial  measures  as  the  pathogenesis  described  may 
suggest. 

Adrenal  Type.  Although  Josue  and  others  recognize  a  clearly 
defined  adrenal  syndrome,  both  the  prodromic  and  late  signs  they 
describe  have  seemed  to  me  to  occur  in  the  autolytic  period  as  well. 
Indeed,  it  is  difficult  to  understand  how  it  can  be  otherwise,  since 
the  power  of  the  adrenal  secretion  to  excite  thyroid  activity  causes 
both  these  organs  to  act  synchronously.  It  has  seemed  to  me,  how- 
ever, that  in  cases  in  which  sustained  exertion,  as  in  laborers,  letter- 
carriers,  bicylists,  etc.,  the  adrenal  factor  could  be  discerned  to  a 
certain  extent.  In  such  cases,  the  blood-pressure  is  apt  to  be  some- 
what high — 150  mm.  or  thereabouts — the  patient  may  complain  of 
headache  or  rather  of  fullness  about  the  brow  and  of  cramps  in  the 
calves  of  the  legs.  He  may  be  irritable,  or,  conversely,  exuberant, 
flushed  and  buoyant,  "feeling  like  being  on  the  go  all  the  time," 
as  one  expressed  it.  The  pulse  may  be  slow  and  full  and  the  heart 
beat,  though  normal,  somewhat  forcible.  Epistaxis,  and  conditions 
which  the  patient  defines  as  nervousness,  palpitations,  sleeplessness, 
especially  during  the  early  morning  hours,  a  nervous  or  hacking 
cough,  asthenia  or  a  "wheezing  under  the  breast  bone,"  and  often 
gastric  disorders  in  which  hyperchlorhydria  and  pyrosis  are  promi- 
nent signs.  In  fact,  it  is  usually  for  some  gastric  derangement  with 
constipation,  or  for  muscular  pains  attributed  to  rheumatism,  that 
the  patient  presents  himself. 

Such  men  may,  in  keeping  with  what  is  observed  in  hyperneph- 
roma, show  great  muscular  development — sufficient  in  three  cases 
that  I  have  seen  to  suggest  larval  acromegaly — and  perspire  very 
freely.  They  may  also  show  venous  engorgement,  venous  pulse, 
facial  congestion — all  symptoms  of  hyperadrenia — all  due  to  thick- 
ening of  the  arterial  coats,  especially  of  the  muscular  media.  Con- 
versely, they  may  appear  pale,  complain  of  cold  extremities,  and 
stand  cold  weather  badly.  This  may  be  due  to  constriction  of  the 
peripheral  arterioles,  but  in  all  likelihood  to  the  onset  of  organic 
lesions. 

Such  cases  yield  readily  to  measures  calculated  to  reduce  the  func- 
tional activity  of  the  adrenals.  A  less  arduous  occupation,  absten- 
tion from  meat,  coffee,  tea  and  alcohol,  to  lower  the  vascular  ten- 
sion, often  suffice.     If  the  vascular  tension  is  high,  the  condition 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        41 

of  the  kidneys  should  be  looked  into.  As  a  rule  at  this  time,  these 
organs  are  found  normal  though  some  polyuria  be  present.  Spirit 
of  nitrous  ether  may  then  be  used  in  small  doses  three  times  daily 
to  reduce  the  tension  if  it  fails  to  recede  after  a  few  days,  and  also 
small  doses  of  sodium  bromide  and  chloral  on  retiring  if  the  tend- 
ency to  insomnia  persists. 

The  iodides  at  this  stage  arc  harmful.  So  are  strychnine,  digi- 
talis and  tonics  in  general,  most  of  which  stimulate  the  adrenals 
and  aggravate  the  trouble. 

Autolytic  Type.  This  type  may  either  begin  with  the  symptoms 
described,  where  the  causative  poison  is  one  acting  slowly,  as  is  the 
case  in  the  large  proportion  of  patients  in  whom  the  disease  is  due 
to  the  excessive  use  of  proteins,  alcohol,  coffee,  etc.,  or  may  follow 
a  febrile  disease.  Here,  we  are  no  longer  dealing  with  erethism 
due  merely  to  exaggerated  metabolism,  but  with  the  symptoms  of 
the  damage  the  latter  is  doing  or  has  done  to  the  blood  vessels.  In 
the  overfed  or  overworked,  as  previously  stated,  we  witness  the 
phenomena  of  stimulation :  flushed  face,  brilliant  eyes  with  perhaps 
slight  precordial  pain  after  an  unusual  copious  meal,  or  unusual 
exertion  as  running,  climbing,  etc.,  and  general  vivacity ;  but,  it  is 
important  to  note  that  this  stage  of  primary  exuberance  corresponds 
with  the  febrile  period  of  an  infection  which  may,  though  relatively 
very  short,  do  as  much  damage  to  the  blood  vessels  as  years  of  over- 
eating, hard  labor,  etc.  The  patient,  after  either  of  these  pre- 
liminary periods,  long  or  short,  passes  into  what  is  now  mistaken, 
and  described  as  such  in  most  text-books,  as  the  early  manifesta- 
tions of  arteriosclerosis,  but  which  are  in  reality  those  of  its  second 
stage.  While  in  the  first  stage,  the  vessels  are  merely  congested  and 
more  or  less  thickened  or  hypertrophied,  thus  causing  the  blood- 
pressure  to  be  more  or  less  high,  in  this  second  stage,  organic  lesions 
have  already  compromised  their  power  to  contract  equably  in  all 
parts  of  the  circulatory  tree.  This  may  affect  one  part  of  the  latter 
more  than  another,  or  a  morbid  process  may  be  awakened  in  one 
or  more  organs,  the  brain,  cord,  liver,  kidneys,  etc.,  according  to  the 
inherited  or  acquired  susceptibility  of  these  structures.  It  is  then 
that  we  begin  to  witness  the  syndrome  which  is  usually  compared 
to  neurasthenia,  which  is  really  that  of  a  debilitated  circulation : 
loss  of  vigor,  lassitude,  or  myasthenia,  drowsiness,  postural  vertigo, 
faintness,  more  or  less  marked  visual  disturbances,  phobias,  head- 
aches, dyspnea  on  exertion,  transitory  hemianopsia  or  amaurosis — 
the  whole  gamut  with  which  you  are  all  so  familiar. 


42        THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

Here  again,  prophylactic  measures,  a  reduction  of  proteins — a 
feature  that  is  harmful  in  these  cases,  which  a  vegetable  diet,  by 
supplying  alkaline  salts,  tends  to  counteract  and  gradually  to  elimi- 
nate. Although  the  arteries  are  already  damaged,  the  process  of 
repair  in  them  is  very  active,  often  by  insular  scleroses  so  disposed 
longitudinally  as  to  restore  the  contractile  activity  of  the  vessels  to 
a  remarkable  degree.  „ 

As  to  drugs,  is  it  rational  to  give  the  iodides  in  cases  in  which  the 
thyroid  secretion  laden  with  iodine  in  organic  combination  is  taking 
part  in  the  cellular  destruction  of  the  arterial  walls?  I  am  glad  to 
note  that  the  experience  of  Dr.  L.  Faugeres  Bishop  coincides  with 
mine  in  this  particular.  In  fact,  he  refers  to  patients  who  were 
rendered  uncomfortable  by  the  abuse  of  iodides  and  suggests  the 
possibility  of  iodism  superadded  to  the  symptoms  of  the  disease. 
This  is  precisely  what  happens  when  the  iodides  are  added  to  the 
thyroidine  with  which  the  tissues  are  laden,  the  thyroid  being  already 
overactive.  The  indications  are  precisely  the  opposite :  No  remedies 
until  the  toxic  factor,  whatever  that  may  be,  dietetic,  intestinal, 
bacterial,  etc.,  is  eliminated  prophylactically.  If  after  a  couple  of 
months,  the  patient  does  not  show  the  sense  of  well-being  which 
usually  follows  well  addressed  prophylactic  measures,  and  still 
shows  neurasthenia-like  symptoms,  it  is  because  katabolism  and 
arterial  degeneration  is  still  proceeding,  owing  mainly  to  hyperplasia 
of  the  thyroid.  Arsenic  in  small  doses,  say  3  minims  of  Fowler's 
solution,  t.i.d.,  as  shown  by  Mabille  and  confirmed  by  Ewald,  Hein- 
rich  Stern  and  others,  will  then  gradually  reduce  the  thyroid  ereth- 
ism. In  cases  showing  actual  hyperthyroidia,  or  larval  Graves's 
disease,  ergotin,  or  the  coal  tars,  are  helpful  to  counteract  the  vas- 
cular supply  of  both  the  thyroid  and  adrenals  and  thus  inhibit  their 
secretory  activity.  It  should  be  remembered  that  rest  is  an  impor- 
tant feature  wherever  exuberant  activity  of  the  ductless  glands  is 
in  order.  The  iodides  and  digitalis — the  latter  an  active  adrenal 
stimulant,  a  fact  in  which  several  experimenters  have  also  sustained 
me — are  particularly  valuable  late,  i.e.,  when  the  thyroid  and  adre- 
nals have  been  in  a  measure  exhausted  through  the  excessive  ac- 
tivity that  the  original  cause  of  the  trouble,  some  toxemia,  endo- 
genous or  exogenous,  has  imposed  upon  them. 

Denntrition  Type.  When  in  the  form  just  described  exhaustion 
of  the  adrenals  and  thyroid  has  occurred  through  the  excessive 
activity  imposed  upon  them  by  toxics,  they  have  reached,  from  my 
viewpoint,  the  condition  that  prevails  in  what  has  been  termed  the 


THE  AMERICAX  COXGRESS  OX  IXTERXAL  MEDICIXE        43 

presenile  or  senile  form  of  arteriosclerosis.  In  some  persons,  even 
those  of  frugal  habits,  this  develops  early  because  their  ductless 
glands,  through  inherited  debility,  are  unable  to  bear  the  least  exac- 
erbation of  activity  imposed  upon  them  occasionally  by  even  slight 
intercurrent  disorders,  fatigue,  emotions,  shock,  worry,  i.e.,  the  wear 
and  tear  of  existence.  Important  in  this  connection  also,  is  the 
influence  of  the  diseases  of  children,  particularly  those  attended  by 
fever.  Interstitial  hemorrhages  of  both  adrenals  and  thyroid  suffi- 
cient to  reduce  considerably  their  functional  efficiency  cause  lesions 
which,  in  after  life,  leave  the  organs  on  the  very  threshhold  of 
physiological  activity.  Though  able  to  carry  on  just  the  needs  of 
commonplace  existence,  they  prove  inadequate  to  meet  the  needs  of 
any  intercurrent  issue.  Such  people  are  very  early  the  prey  of  in- 
tercurrent diseases,  tuberculosis  and  pneumonia  in  particular.  They 
grow  old  early  because,  as  the  wear  and  tear  of  life  impinges  upon 
their  ductless  glands,  denutrition  progresses,  including  that  of  the 
arterial  system.  Premature  involution  of  the  thymus,  as  I  have 
shown  elsewhere,  may  initiate  this  denutrition  type  in  the  young. 

The  treatment  here  is  precisely  the  opposite  of  that  indicated  in 
the  foregoing  forms.  Organotherapy,  provided  thyroid  and  adrenal 
gland  and  any  other  organic  product  used  be  given  in  small  doses, 
is  of  very  great  value.  The  iodides,  also  in  small  doses,  digitalis 
and  strophanthus  are  all  exceedingly  helpful.  A  reduced  diet  here 
is  not  indicated.  Besides  the  thyroid  and  adrenal  preparations 
already  mentioned,  some  pancreatic  product  should  be  added  to  fa- 
cilitate intestinal  digestion,  sustain  tissue  life  and  contribute  with 
the  other  organic  products  administered  to  the  defensive  resources 
of  the  organism. 

Such  are,  gentlemen,  the  relations  of  the  ductless  glands  to  early 
arteriosclerosis  as  I  interpret  them.  They  seem  to  me,  at  least,  to 
be  borne  out  by  experimental  and  clinical  evidence,  the  bulk  of 
which  could  not  be  submitted  owing  to  lack  of  space.  So  strong 
is  this  evidence  in  the  aggregate  that  it  seems  to  me  possible  to 
conclude  that  arteriosclerosis  is  the  result  of  excessive  or  deficient 
activity  of  certain  ductless  glands,  the  thyroid  and  adrenals  in  par- 
ticular. 

DISEASES    OF   THE    HEART. 

The  views  submitted  concerning  the  vascular  system  apply  to  cer- 
tain organic  cardiac  disorders  quite  as  well.  A  brief  summary  of 
the  relations  between  the  adrenals  and  thyroid  on  the  one  hand, 
and  the  heart  on  the  other,  will  therefore  suffice. 


44       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

Acute  dilatation  of  the  heart,  such  as  the  heart  strain  observed 
in  otherwise  healthy  athletes,  and  the  so-called  irritable  heart  in  sol- 
diers, first  described  by  the  late  J.  M.  DaCosta,  is  but  an  example 
of  adrenal  exhaustion,  Brown-Sequard,  and  forty  years  later,  Oliver 
and  Schafer,  having  shown  that  the  secretion  of  the  adrenals  caused 
contraction  of  the  heart  muscle.  This  secretion  is  poured  into  the 
inferior  vena  cava,  the  blood  of  which  carries  it  to  the  right  heart. 
Now  it  is  precisely  the  right  heart  which  is  dilated.  That  digitalis 
or  strophanthus  which,  as  already  stated,  stimulate  the  'adrenals, 
should  be  indicated  seems  obvious.  Yet  is  this  the  best  treatment? 
No;  for  we  are  dealing  with  extreme  deficiency  of  adrenal  secre- 
tion owing  to  exhaustion  of  the  adrenals — what  might  well  be 
termed  acute  hypoadrenia.  Deficiency  of  fluids  being  also  a  result 
of  severe  exertion,  hypodermoclysis,  in  small  doses,  with  adrenalin, 
or  a  fluid  preparation  of  posterior  pituitary,  owing  to  its  wealth  in 
adrenal  substance,  with  absolute  rest  to  enable  the  adrenals  to  re- 
cover their  secretory  activity,  are  more  rational  resources. 

Hypertrophy  and  Degeneration.  This  overgrowth  of  cardiac 
muscular  tissue  is  usually  attributed,  in  arteriosclerosis,  to  the  in- 
creased resistance  to  the  blood  column  imposed  by  the  diseased  ves- 
sels, the  average  caliber  of  which  is  narrowed  when  there  is  an 
extreme  degree  of  sclerosis  of  the  visceral  arteries  and  larger  ves- 
sels, according  to  some  authors.  Yet,  we  know  that  thickening  of 
the  vessels  may  occur  without  high  blood-pressure,  in  arteriosclero- 
sis, and  that,  precisely  as  is  the  case  in  the  latter  disease,  prolonged 
severe  exertion,  such  as  that  to  which  blacksmiths,  longshoremen, 
bicyclists,  etc.,  are  exposed,  brings  on  hypertrophy  of  the  heart. 
The  fact  that  this  type  is  known  as  "primary  idiopathic  hyper- 
trophy" shows  that  the  nature  of  its  pathogenesis  is  unknown.  In 
truth,  when  we  analyze  such  cases  with  any  degree  of  care,  we  find 
that  many  of  them  are  in  that  stage  of  arteriosclerosis  in  which 
general  erethism  prevails,  i.e.,  before  the  stage  of  degeneration  has 
occurred.  After  a  time  there  occurs  in  the  heart  not  as  a  result  of 
increased  blood-pressure  as  is  now  assumed,  but  as  a  result  of  au- 
tolysis, what  Tyson  and  Fussell  describe  as  the  "arterial  sclerosis 
atheroma  and  fibroid  thickening  so  constantly  seen  in  valves  and 
heart-walls." 

Briefly,  the  causes  being  precisely  the  same,  both  the  type  of 
hypertrophy  and  subsequent  degeneration  described  are  but  counter- 
part of  the  form  of  arteriosclerosis  I  have  traced  to  excessive  ac- 
tivity of  the  thyroid  and  adrenals.     Nor  do  the  treatments  dififer. 


TUB  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        45 

digitalis  and   its  congerers  being  harmful    in   llu-   hypertrophic  or 
erethic  stage,  but  beneficial  in  the  degenerative. 

This  cursory  survey  of  a  few  cardiovascular  diseases  illustrates 
the  importance  of  including  the  ductless  glands  in  our  conception 
of  their  pathogenesis  and  treatment.  Indeed,  owing  to  the  non- 
recognition  of  these  organs,  I  may  add,  a  large  proportion  of  un- 
timely deaths  occur  in  acute  diseases  of  many  organs,  and  par- 
ticularly the  heart,  which  might  be  avoided. 

DEMENTIA   PRECOX. 

Just  as  cardiovascular  diseases  now  stand  first  among  those  which 
cause  death  prematurely,  so  does  dementia  precox  stand  first  as  the 
destroyer  of  the  mind  of  the  young.  In  a  recent  paper.  Bayard 
Holmes  states  that  of  the  14,000  insane  in  Illinois,  at  least  60  per 
cent,  are  cases  of  dementia  precox.  This  probably  represents  the 
average  throughout  the  United  States.  In  other  words,  over  one- 
half  of  the  inmates  of  our  asylums,  to  say  nothing  of  the  many  that 
are  not  committed,  suffer  from,  or  from  the  complications  of,  this 
dread  mental  disease  of  adolescence. 

Dementia  precox  is  considered  in  the  present  connection  for  two 
main  reasons :  /.  to  recall  the  importance  of  a  gland,  the  thymus, 
which,  in  the  pathogenesis  of  general  diseases,  has  been  almost 
entirely  neglected,  and,  2.  to  inquire  from  our  colleagues  who  devote 
their  labors  to  psychiatry,  whether,  granting  that  the  thymus  under- 
lies the  development  of  dementia  precox,  the  general  practitioner, 
who  in  practically  every  instance,  sees  the  initial  signs  of  the  dis- 
ease, without  recognizing  their  meaning  (owing  of  course  to  lack 
of  special  training)  could  not  be  familiarized  with  these  early  symp- 
toms sufficiently  to  enable  him  either  to  send  the  patient  to  the 
psychiatrist  before  the  morbid  process  is  irremediable,  or  to  treat 
him  himself  if  a  psychiatrist  is  not  within  reach. 

The  participation  of  the  thymus  in  dementia  precox  was  sug- 
gested to  me  by  the  fact,  confirmed  by  many  clinicians,  that,  as  ob- 
served in  1858  by  Friedlieben,  the  size  and  condition  of  the  thymus 
was  an  index  to  the  state  of  nutrition  of  the  body  at  large.  Four- 
teen years  ago  I  urged,  after  a  careful  study  of  the  relations  of  the 
thymus  to  the  brain,  that  it  took  part  in  the  development  of  the  lat- 
ter, the  deduction  submitted  at  the  time  being  substantially  that 
reached  recently,  viz.,  that  the  function  of  the  thymus  was  to  supply 
through  the  agency  of  its  lymphocytes  the  excess  of  phosphorus  in 
organic  combination  which  the  body,  particularly  the  osseous,  ner- 


46        THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

vous  and  genital  systems,  including  the  brain,  required  during  its 
development  and  growth,  i.e.,  during  infancy,  childhood,  and  ado- 
lescence. I  will  not  submit  you  to  the  torture  of  listening  to  the 
evidence  already  pul:)lished  elsewhere,  but  will  merely  recall  a  few 
salient  facts. 

Considerable  confusion  concerning  the  physiology  of  the  thymus 
is  evident  in  the  literature  of  the  subject  even  now.  There  are  at 
least  ten  theories  available  as  to  its  functions.  The  confusion  lies 
in  the  fact  that  each  author  thought  his  own  theory  explained  the 
entire  role  of  the  organ,  whereas  it  failed  to  do  so  when  submitted 
to  analytical  scrutiny.  Yet  each,  with  one  exception,  had  merit  in 
the  sense  that  it  represented  a  bona  fide  feature  of  the  problem  as 
a  whole.  The  exception,  that  is  to  say,  the  function  which  seemed 
to  find  no  substantial  support  was  the  theory  which  endowed  the 
thymus  with  an  internal  secretion.  The  evidence  sustained  strongly, 
however,  the  view  that  its  lymphocytes  carried  nucleoproteids,  rich 
of  course  in  phosphorus  as  are  all  nucleins,  to  the  organism  at 
large,  including  the  brain  and  nervous  system,  for  the  development 
of  their  neurons. 

Another  feature  which  delayed  progress  in  ascertaining  the  func- 
tions of  the  thymus  was  the  non-recognition  by  many  experimenters 
of  the  fact  that  a  proper  selection  of  the  animals  and  removal  of 
the  thymus  almost  immediately  after  birth  alone  showed  its  influence 
on  the  body  growth,  the  twelve  years  before  puberty  in  man,  being 
represented  in  many  animals  by  but  a  few  days.  When  these  and 
other  facts  were  taken  into  account,  the  functions  of  the  thymus 
as  above  described  seemed  to  impose  themselves. 

The  wealth  of  the  thymic  lymphocytes  in  nucleins  coincides  with 
the  all-important  influence  which  the  thymus  seems  to  possess  in 
the  production  of  idiocy.  At  Bicetre  Hospital,  according  to  IMorel, 
75  per  cent,  of  408  non-myxedematous  idiotic  children,  ranging  from 
I  to  5  years  old,  examined  post  mortem  from  1890  to  1903,  showed 
absence  of  the  thymus.  At  the  request  of  Bourneville,  Katz  per- 
formed autopsies  in  61  mentally  normal  children,  varying  in  age 
from  I  month  to  13  years,  who  had  died  of  various  diseases.  In  all 
of  these  the  thymus  was  present.  Conversely,  in  28  mentally  weak 
children  examined  post  mortem  by  Bourneville,  the  thymus  was  ab- 
sent. These  observations  correspond  with  the  results  of  complete 
thymectomy  in  animals.  Basch,  Klose  and  ^  ogt,  Morel  and  others 
have  observed  mental  disorders  in  pujipics  the  fifth  or  sixth  month 
after  removal  of  the  organ. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        47 

While  the  thymus  thus  shows  itself  capable  of  supplying  nucleins 
to  the  organ  of  mind,  dementia  precox  also  shows  in  many  ways 
some  connection  with  the  thymus.  There  is  a  marked  reduction  of 
the  lymphocytes  in  this  disease  which  the  therapeutic  use  of  thymus 
gland  corrects.  Deficiency  of  nucleins  is  also  shown  by  the  excess 
of  purin  bases  in  this  disease.  Defective  metabolism  of  the  bones 
is  shown  by  the  frequent  presence  of  osseous  disorders  such  as 
retarded  growth,  rickets,  osteomalacia  and  fragilitas  ossiuni.  Fi- 
nally, therapeutically,  Ludlum  and  Corson-White  obtained  excellent 
results  in  3  out  of  6  cases  of  dementia  precox,  the  three  patients  in 
whom  it  failed  being  old  and  much  demented.  While  these  cases 
are  (juite  insufficient  in  number  to  demonstrate  the  value  of  thymus 
gland  in  the  disease,  they  are  at  least  suggestive  when  considered 
with  the  other  data  submitted. 

The  familiar  functional  relationship  between  the  various  ductless 
glands  suggests  that  asthenic  disorders  of  the  latter  should  show 
some  mental  kinship  with  dementia  precox.  The  English  Myxe- 
dema Committee,  after  an  extensive  investigation,  found  that  nearly 
one-half  of  the  patients  suffering  from  myxedema  also  showed  men- 
tal disorders.  The  types  most  frecjuently  observed  were  melan- 
cholia with  delusions  and  hallucinations,  and  due,  as  I  suggested 
elsewhere,  to  lowered  metabolism  occurring  as  a  result  of  the  de- 
ficient thyroid  activity,  acute  or  chronic  mania  and  dementia  due, 
from  my  viewpoint,  to  the  accumulation  in  the  tissues,  including 
the  brain,  of  intermediate  products  of  metabolism  which  a  normal 
supply  of  thyroid  secretion  would,  in  conjunction  with  other  internal 
secretions,  have  converted  into  eliminable  products.  Bernstein 
found  the  stigmata  of  myxedema  in  practically  all  cases  of  dementia 
precox. 

The  mental  symptoms  of  Addison's  disease  also  showing  consid- 
erable kinship  with  those  of  myxedema,  we  are  brought  to  realize 
that  thymic  deficiency  entails  more  or  less  deficiency  of  the  other 
ductless  glands  and  that  we  find  in  the  stigmata  of  these  various 
organs^  clues  to  a  possible  underlying  cause  of  dementia  precox 
which  may  so  far  have  been  overlooked. 

In  discussing  the  relationship  between  the  diseases  of  the  duct- 
less glands  and  cardiovascular  diseases  I  could  speak  from  the  stand- 
point of  clinical  experience,  but  dementia  precox  being  out  of  my 
line,  I  can  only  bid  for  light,  hoping  that  the  following  stigmata  of 
insufficiency  of  the  three  main  ductless  glands  apparently  concerned 
in  the  morbid  process  may  prove  of  some  service.     Indeed,  in  this 


48        THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

disease  as  in  arteriosclerosis,  the  great  desideratum  appears  to  be 
recognition  of  the  initial  symptoms,  so  as  to  make  it  possible  perhaps 
to  thwart  its  progress.  The  stigmata  referred  to,  reduced  to  their 
simplest  expression,  are  briefly  as  follows : 

Stigmata  of  Thymus  Deficiency,  i.  Deficient  development  of  the 
osseous  system  and  of  the  epiphyses,  and  deformities  suggesting 
rickets  or  osteomalacia,  due  to  inadequate  assimilation  of  calcium 
owing  to  the  deficiency  of  thymic  nucleins  which  take  part  in  the 
building  up  of  calcium  phosphate;  undersized  stature. 

2.  Deficient  mental  development  due  to  the  insufficient  production 
of  thymic  nucleins  to  supply  the  neurons  of  the  central  nervous  sys- 
tem during  its  development. 

3.  A  low  relative  lymphocyte  count  due  to  the  inadequate  forma- 
tion of  these  cells  by  the  thymus. 

Stigmata  of  Thyroid  Deficiency,  i.  Subnormal  temperature,  cold 
extremities  due  to  deefctive  oxidation  and  metabolism,  the  thyroid 
collaborating  actively  with  the  adrenals  and  thymus  (before  puberty 
only  as  to  the  latter  gland)  in  sustaining  this  process.  Tendency 
to  obesity. 

2.  A  doughy  dry  skin,  with  at  times  cervical  or  axillary  fat  pads 
due  to  plasmatic  infiltration  and  circulatory  torpor ;  also  in  very 
marked  cases,  scaly  skin  and  dry  brittle  hair  and  nails  due  to  de- 
ficient nutrition  of  these  structures. 

3.  Mental  torpor  or  deficiency  where  true  thyroid  stigmata  are 
discernible,  complete  development  of  the  brain  requiring  perfect 
coordination  of  the  thyroid,  adrenal,  and  thymic  functions. 

Stigmata  of  Adrenal  Deficiency,  i.  Muscular  weakness  and  ema- 
ciation, pallor,  deficient  hair  growth,  sensitiveness  to  cold,  subnormal 
temperature,  all  due  to  deficient  tissue  oxidation  and  recession  of 
the  blood  mass  into  the  splanchnic  area. 

2.  Weak  heart  action  and  pulse,  low  blood-pressure,  and  consti- 
pation due  to  deficient  peristalsis,  the  result  in  turn  of  torpor  of 
the  intestinal  muscular  layer. 

3.  Pigmentation,  sometimes  limited  to  bronze  areas  on  the  back 
of  the  hands,  and  freckles. 

4.  Mental  torpor,  slow  intellection  or  even  idiocy  where  the 
adrenal  deficiency  is  initiated  in  utero. 

In  all  these  abnormalities  we  must  bear  in  mind  the  influence 
of  toxics,  exogenous  and  endogenous,  which  are  now  known  to 
bear  so  great  an  influence  on  mental  diseases.  The  functions  of  the 
ductless  glands  including  that  of  converting  poisons  into  eliminable 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        49 

wastes,  their  insufficiency  entails  an  accumulation  of  these  poisons, 
or  of  intermediate  wastes^which  are  also  toxic — and,  therefore, 
the  very  conditions  which  promote  certain  forms  of  mental  aberra- 
tion. Important  also,  are  the  diseases  of  children  in  the  genesis  of 
dementia  precox,  since,  as  we  have  seen,  hemorrhages  in  the  various 
ductless  glands  may  then  occur,  which  are  followed  by  sclerotic 
lesions  that  impair  their  efficiency.  But  here,  another  feature  must 
not  be  overlooked:  the  lesions  that  are  sometimes  produced  in  the 
brain  itself,  in  the  course  of  acute  febrile  infections. 


THE  RELATIONSHIP  OF  THE  DUCTLESS  GLANDS  TO 

ARTERIAL  DISEASES 

By  JUDSON   DALAND 
Philadelphia 

Dr.  Sajous,  a  pioneer  in  this  field  of  work,  has  rendered  a  signal 
service  in  directing  attention  to  the  relationship  of  the  ductless 
glands  to  arterial  disease,  and  as  a  universally  recognized  author- 
ity on  internal  secretions,  his  opinions  demand  thoughtful  con- 
sideration. 

His  communication  is  important  because  of  the  frequency  and 
seriousness  of  diseases  of  the  arteries,  the  alarming  increase  ob- 
served in  recent  years,  the  original  views  advanced  as  to  the  causa- 
tion of  arteriosclerosis  by  irregularities  of  the  function  of  ductless 
glands,  and  the  new  measures  advocated  for  prevention  and  treat- 
ment. 

Arteriosclerosis  is  erroneously  employed  as  a  synonym  for  dis- 
ease of  the  arteries,  and  leads  to  confused  concepts  of  pathology. 
It  is  a  subdivision  of  diseases  of  the  arteries,  and  occurs  as  a  tisnal 
or  occasional  result  of  different  pathologic  processes  due  to  dif- 
ferent causes.  Atheroma  due  to  age  should  be  sharply  differentiated. 

Accumulated  evidence  secured  at  the  bedside  and  by  experimen- 
tation clearly  proves  that  overfunctionating  adrenals  or  thyroids 
produce  arteriosclerosis,  more  especially  if  long  continued  or  re- 
curring with  sufficient  frequency.  The  exact  manner  in  which 
sclerosis  is  produced  is  open  to  question,  and  views  of  observers 
differ.  The  solution  of  the  question  is  beset  by  many  clinical  and 
experimental  difficulties,  and  is  further  complicated  by  the  frequent 
association  of   multiple  causes.     Blood   vessels  vary   congenitally. 


50       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

Some  individuals  possess  unusual  resistance  to  vascular  disease, 
and  a  few  show  sclerosis  as  early  as  the  fifth  or  seventh  year  with- 
out apparent  cause.  It  is  conceivable  that  these  vessel  wall  changes 
are  not  primary  and  structural,  but  may  be  secondary,  due  to  hyper- 
functionating  ductless  glands. 

Long  continued  excessive  muscular  work  causes  arteriosclerosis, 
and  although  the  supply  of  adrenalin  is  increased,  this  increase  is 
a  physiologic  response  to  the  needs  of  the  musculature,  and  there- 
fore overzvork  is  the  primary  cause  of  the  sclerosis.  The  big  mus- 
cles of  the  blacksmith's  right  arm  are  occupational.  Long  contin- 
ued excessive  cerebral  work  causes  sclerosis,  more  especially  of  the 
cerebral  vessels,  and  here  again  the  ductless  glands  are  called  upon 
for  increased  secretions,  but  the  primary  cause  is  excessive  brain 
work. 

The  habitual  ingestion  of  several  quarts  of  water  daily  by  a 
brickmaker  caused  advanced  arteriosclerosis,  a  part  of  which  was 
due  to  excessive  labor.  The  transportation  by  the  circulatory  ap- 
paratus of  a  weight  represented  by  so  large  a  quantity  of  water 
adds  greatly  to  the  work  of  the  cardiovascular  system.  Diabetes  is 
often  associated  with  the  ingestion  of  large  volumes  of  water, 
and  in  a  similar  manner  produces  arteriosclerosis,  a  part  of  which, 
however,  is  due  to  the  products  of  altered  metabolism,  and  an 
over-  or  under-activity  of  the  thyroid  or  adrenals.  Syphilis  causes 
endarteritis,  often  obliterative,  and  aneurisms  are  common.  The 
spirocheta  pallida  has  been  observed  in  the  wall  of  the  artery,  and 
this  organism  and  its  toxins  are  the  cause  of  the  endarteritis.  Rheu- 
matism is  accepted  as  a  cause  of  arteriosclerosis.  Recently  evidence 
has  been  accumulated  proving  that  rheumatism  is  in  reality  a  sec- 
ondary manifestation  of  a  chronic  septic  focus,  and  is  usually  asso- 
ciated with  one  of  the  strains  of  streptococci,  which  has  been  ob- 
served in  the  wall  of  the  artery.  Whatever  role  the  ductless  glands 
play  in  this  disease  is  secondary,  and  the  toxic  substances  produced 
by  the  streptococci  and  by  katabolism  aid  in  the  production  of  the 
vascular  changes. 

Gonorrhea,  tuberculosis,  pneumonia,  and  typhoid  cause  arterial 
disease,  and  their  specific  organisms  have  been  found  in  the  arterial 
lesion.  When  tuberculosis,  pneumonia,  or  gonorrhea  is  associated 
with  mixed  infection,  arterial  disease  is  more  likely  to  occur.  The 
ductless  glands  in  these  diseases  play  a  secondary  or  associated  role. 

Arteriosclerosis  has  followed  scarlatina,  variola,  measles,  influ- 
enza, typhoid  and  typhus  fever.     It  is  possible  that  the  so-called 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        51 

rheumatism  and  the  communicable  diseases  already  mentioned  stim- 
ulate the  ductless  glands,  and  secondarily  produce  the  autolytic  or 
adrenalin  type  of  arteriosclerosis.  On  the  other  hand,  it  should 
not  be  forgotten  that  toxins  made  by  pathogenic  organisms  may 
injure  one  or  more  coats  of  the  artery,  and  so  provide  favorable 
conditions  for  their  lodgment  and  growth. 

Conflicting  views  exist  as  to  the  etiologic  relationship  of  tea,  cof- 
fee, alcohol  and  tobacco  to  arterial  disease.  Although  Russians 
consume  large  quantities  of  tea,  no  effect  was  observed  among  the 
patients  in  many  of  the  hospitals  of  Petrograd  and  Moscow. 

Coffee  exerts  a  marked  influence  over  the  cardiovascular  system 
and  in  certain  cases  apparently  causes  arteriosclerosis,  especially 
observable  in  Hungary,  where  this  beverage  is  consumed  in  large 
quantities.  Many  cases  of  arteriosclerosis,  supposed  to  be  due  to 
coffee,  are  neurasthenics,  and  the  role  of  the  ductless  glands  may 
therefore  be  larger  than  hitherto  supposed. 

Tobacco  produces  a  marked  influence  over  the  cardiovascular 
and  nervous  systems,  and  when  used  in  great  excess,  may  also 
cause  degeneration  of  the  nerve  endings.  It  is  difficult  to  assign  to 
tobacco  its  exact  percentage  of  value  etiologically  in  the  production 
of  arteriosclerosis,  because  it  is  almost  constantly  associated  with 
the  other  causes  of  this  disease. 

A  typical  example  occurred  in  three  brothers,  all  using  tobacco 
to  great  excess,  leading  to  the  supposition  that  it  was  the  chief 
cause  of  the  arteriosclerosis.  They  were  markedly  neurotic,  living 
a  strenuous  business  life,  and  at  times  indulging  in  excesses  of  food 
and  wine.  These  patients  doubtless  also  suffered  from  hypothy- 
roidia  and  hypoadrenia. 

The  products  of  decomposition  or  fermentation  of  the  intestinal 
contents  produce  arteriosclerosis,  and  may  also  stimulate  the  duct- 
less glands. 

French  observers  have  long  maintained  this  opinion,  some  believ- 
ing that  paracresol  and  indol  of  intestinal  origin,  due  to  the  decom- 
position of  nitrogenous  materials,  are  able  to  evoke  arterial  disease. 

All  are  agreed  that  gout  causes  arteriosclerosis.  Although  excess 
in  food,  especially  rich  in  protein,  with  wine  and  insufficient  exer- 
cise, are  the  chief  causes,  many  attacks  occur  in  the  absence  of 
these  causes,  apparently  due  to  exhaustion  or  disturbances  of  the 
nervous  system,  well  explained  by  Dr.  Sajous'  belief  that  katabolism 
may  be  induced  by  lessening  of  the  activity  of  the  adrenal  center, 
with  consequent  diminution  of  the  adreno-oxidase ;  and  he  further- 


52       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

more  believes  that  this  explanation  is  equally  true  of  lead  poisoning. 

From  the  foregoing,  it  is  clear  that  in  a  number  of  instances 
the  primary  cause  of  arteriosclerosis  may  be  assisted  by  hypo- 
or  hyperactivity  of  the  thyroid  and  adrenals. 

Arteriosclerosis  and  hypertension  usually  accompany  kidney  dis- 
ease with  renal  inefficiency. 

The  retention  of  unknown  toxic  substances  in  the  blood  at  first 
causes  arterial  spasm  and  later  sclerosis,  hitherto  supposed  to  be 
solely  due  to  the  direct  action  of  these  toxic  agents  upon  the  vessel 
walls.  It  is  probable  that  hyperfunctionating  ductless  glands  assist 
this  process. 

Hypertension  is  a  usual  secondary  manifestation  of  arterioscler- 
osis, and  also  occurs  in  many  other  diseases.  When  marked,  it  could 
cause  or  increase  already  existing  arteriosclerosis  by  its  physical 
effect,  precisely  as  has  been  observed  in  sclerosis  of  the  pulmonary 
arteries,  with  no  sclerosis  elsewhere,  due  to  emphysema.  Hyper- 
tension may  occur  as  a  sign  of  pre-sclerosis,  or  as  a  danger  signal 
of  advanced  sclerosis. 

With  notable  uniformity  Graves'  disease  is  associated  with  arte- 
rial walls  that  are  degenerated  and  thickened  and  with  increased 
blood  pressure.  It  is  believed  that  these  changes  are  due  primarily 
to  hyperthyroidia  and  later  to  variations  in  this  secretion.  Addi- 
tional unknown  factors  also  probably  exist,  and  there  may  be  asso- 
ciated disease  of  the  thymus. 

Recent  observations  have  clearly  shown  that  anxiety,  worry,  fear, 
and  what  is  usually  understood  by  the  term  "strenuous  living" 
cause  hyperadrenia,  which  produces  arteriosclerosis.  These  causes 
of  arterial  disease  are  chiefly  responsible,  in  the  judgment  of  the 
writer,  for  tJie  remarkable  increase  in  arterial  disease  in  recent 
years. 

Dr.  Sajous'  classification  by  types  serves  a  useful  purpose,  not 
only  by  detailing  sequentially  the  mechanism  by  which  internal 
secretions  produce  sclerosis  of  the  arteries,  but  also  by  stimulating 
inquiry,  observation,  and  experimentation.  In  order  to  emphasize 
my  argument  with  this  aspect  of  the  problem,  and  to  encourage  dis- 
cussion, the  essential  features  of  each  type  are  briefly  summarized: 

An  important  feature  of  the  autolytic  type  is  the  fact  that  trypsin, 
jpancreatic  in  origin,  is  the  ferment  in  the  leukocyte  which  makes 
it  a  phagocyte,  able  to  destroy  bacteria  in  the  intestinal  tract,  and 
after  migrating  causes  metabolism  of  proteins,  when  in  an  alkaline 
medium,  and  evokes  katabolism  of  toxic  waste  products,  toxins 


THE  AMliKICAN  CONGRESS  ON  INTERNAL  MEDICINE        53 

and  bacteria.     Tissue  cells  contain  zymogen  or  proferment  of  tryp- 
sin. 

Proteins  in  excess  sensitize  this  proferment,  stimulate  the  thyroid 
and  adrenals  and  so  convert  harmful  surplusage  of  proteins  in  the 
tissue  cells  and  blood  into  eliminable  end-products.  If  now  more 
protein  be  added,  the  stimulation  of  the  thyroid  and  adrenals  is  in- 
creased, thereby  increasing  oxidation  and  causing  fever,  which  acti- 
vates the  tissue  cell  proferment  causing  autolysis  and  initiating 
arteriosclerosis. 

The  adrenal  type  is  characterized  by  hypcradrenia,  causing  con- 
striction of  the  vaso  vasorum  of  small  or  terminal  arteries,  which 
in  turn  causes  lesions  in  the  media  and  later  in  the  other  coats. 

The  denutritional  type  is  characterized  by  hypothyroidia  and 
hydroadrenia,  causing  defective  oxidation  and  metabolism,  which  in 
turn  causes  arteriosclerosis,  with  low  blood  pressure.  These  con- 
ditions have  been  observed  in  myxedema,  obesity,  and  advanced 
diabetes. 

A  study  of  the  symptomatology  of  the  three  periods  in  the  devel- 
opment of  arteriosclerosis  is  of  importance  in  order  to  diagnose 
the  participation  of  the  ductless  glands  in  the  process.  Of  the 
twenty-six  signs  and  symptoms  mentioned,  almost  half  are  com- 
mon to  many  diseases.  Hypertension,  exaltation,  nervousness,  in- 
somnia, pyrosis,  hyperchlorhydria,  venous  engorgement,  venous 
pulse,  palpitation  and  congestion  of  the  face,  most  clinicians  would 
ascribe  to  disturbances  of  the  nervous  and  cardiovascular  systems, 
and  would  forget  the  ductless  glands.  When  all  or  a  part  of  these 
symptoms  are  present  and  no  other  obvious  explanation  exists,  they 
may  be  interpreted  as  the  result  of  aberrations  in  the  function  of 
the  adreno-thyroid  apparatus.  Pallor  of  the  face,  coldness  of  the 
extremities  or  inability  to  withstand  cold  may  be  symptomatic  of 
vasomotor  constriction,  adrenal  in  origin. 

The  symptomatology  of  the  autolytic  and  adrenal  period  of  arte- 
riosclerosis closely  simulates  that  of  neurasthenia,  and  this  view- 
point opens  a  new  field  in  the  therapy  of  this  group,  care  being 
taken  always  first  to  discover  and  remove  the  cause. 

It  is  desirable  that  a  series  of  carefully  observed  cases  presenting 
the  symptoms  of  neurasthenia,  be  studied  so  as  to  determine 
whether  organotherapy  produces  the  desired  results.  A  similar 
study  should  be  made  in  the  denutritional  period,  where  definite 
results  may  be  expected  by  alternately  using  and  withholding 
adrenal,  thyroid,  or  pancreatic  extracts,  the  iodides,  strophanthus, 


54        THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

or  digitalis.  An  intensive  study  of  this  character  would  give  knowl- 
edge as  to  the  frequency  and  variation  of  individual  symptoms,  and 
conditions  under  which  each  appears  or  disappears ;  and  would 
eventually  establish  a  pathognomonic  syndrome.  A  great  need  ex- 
ists for  a  technic  by  which  the  ductless  gland  apparatus  may  be 
accurately  tested. 

It  has  long  been  known  that  in  hyperthyroidia,  toxic  symptoms 
are  promptly  induced  by  two  or  three  grains  of  the  extract  of 
thyroid,  and  perhaps  similar  observations  have  been  made  in  regard 
to  hyperadrenia.  Clinical  observations  of  the  effect  of  other  sub- 
stances should  likewise  be  made,  conjoined  with  a  special  study  of 
the  less  characteristic  symptoms. 

The  recognition  of  the  participation  of  the  ductless  glands  in  the 
production  of  symptoms  occurring  in  arteriosclerosis  fundamentally 
modifies  therapeusis  and  demands  the  use  of  old  and  well-tried 
remedies  from  this  new  point  of  view,  as  well  as  a  more  intelligent 
employment  of  organotherapy. 

Practically,  the  diagnosis  of  the  pre-sclerotic  stage  of  arterial 
disease  is  frequently  impossible,  alzvays  difficult,  and  usually  only 
probable.  Therefore  when  arteriosclerosis  is  suspected  or  diag- 
nosed, prevention  or  arrest  may  be  accomplished  by  the  prompt- 
detection  and  removal  of  one  or  more  of  the  causes  of  arterial 
disease,  coupling  with  this  an  estimate  of  the  status  of  the  duct- 
less glands,  in  order  to  give  the  maximum  aid  to  the  patient  in 
the  minimum  of  time. 

The  greatness  of  Dr.  Sajous'  contribution  consists  in  the  prin- 
ciple that  aberrations  in  the  functions  of  the  ductless  glands,  more 
especially  of  the  thyroid  and  adrenals,  cause  arteriosclerosis.  The 
acceptance  of  this  principle  adds  much  to  our  resources  in  the 
prevention  and  treatment  of  arterial  disease,  and  encourages  the 
expectation  of  a  diminution  in  the  morbidity  and  mortality  of 
arteriosclerosis. 


THE  DUCTLESS  GLANDS  IN  DEMENTIA  PRAECOX 

By  FRANCIS  X.  DERCUM. 

Before  entering  into  a  consideration  of  the  internal  secretions  in 
dementia  praecox,  it  is  important  first  to  turn  our  attention  to  a 
number  of  facts  of  general  but  very  great  significance.  Indeed,  this 
is  absolutely  necessary  in  order  that  the  changes  in  the  glands  of 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        55 

internal  secretion  and  the  possible  role  they  play  may  be  viewed  in 
their  proper  perspective.  We  are  impressed  in  the  beginning  with 
the  large  proportion  of  heredity  in  dementia  praecox.  In  this  all 
observers  are  agreed.  Hereditary  factors  are  variously  estimated 
at  from  fifty-two  per  cent,  by  Schott  to  ninety  per  cent,  by  Zab- 
locka.  No  doubt  the  differences  in  the  percentages  given  by  dif- 
ferent observers  are  due  to  a  divergence  of  view,  first  as  to  what 
should  be  included  under  hereditary  factors,  and  secondly  as  to 
the  affections  which  should  be  embraced  by  the  general  term  de- 
mentia praecox.  Kraepelin,  at  one  time,  found  hereditary  pre- 
disposition to  mental  diseases  in  seventy  per  cent,  of  his  cases, 
though  he  thinks  that  this  may  possibly  have  been  too  high.  He 
states  that  when  the  inquiry  was  limited  to  the  direct  heredity,  i.e., 
to  the  occurrence  of  mental  disease,  suicide,  or  severe  brain  affec- 
tions in  the  parents,  it  yielded  33.7  per  cent.,  which  he  again  re- 
gards as  too  low.  From  whatever  point  of  view  we  approach  the 
subject,  however,  the  facts  justify  the  general  conclusion  as  to  the 
frequency  of  neuropathic  family  histories  in  dementia  praecox. 
Such  histories  present  not  only  instances  of  frank  mental  disease, 
but  also  of  eccentric  or  unusual  personalities,  criminals,  prostitutes, 
tramps,  vagabonds  and  other  degenerates.  The  wide  range  of  the 
hereditary  findings  is  also  a  fact  of  some  significance.  If  the  in- 
quiry be  limited  to  the  direct  transmission  of  dementia  praecox,  we 
find  that  such  transmission  is  relatively  infrequent,  as  a  large  num- 
ber of  cases,  especially  the  hebephrenics  and  catatonics,  never  reach 
parenthood.  It  is  otherwise,  however,  if  we  include  the  older,  the 
paranoid  cases.  Ruedin  from  studies  made  of  Kraepelin's  material 
comes  to  the  conclusion  that  dementia  praecox  is  probably  trans- 
mitted in  accordance  with  the  Mendelian  law  of  heredity  and  ap- 
pears as  a  recessive  quality.  He  regards  the  marked  predominance 
of  the  collateral  and  discontinuous  inheritance  over  the  direct 
inheritance,  the  increase  of  dementia  praecox  resulting  from  in- 
breeding and  the  numerical  relation  of  those  attacked  to  those  re- 
maining normal,  as  in  favor  of  this  view.  The  significance  of  a 
number  of  individuals  of  the  same  family  sufifering  from  dementia 
praecox  cannot  be  questioned.  I  have  personal  knowledge  of  one 
family  in  whom  no  less  than  five  individuals  have  suffered  from 
this  disease.  It  is  also  significant  that  Ruedin — in  keeping  with 
what  has  been  already  said — found  in  the  families  which  he  stud- 
ied, other  affections  such  as  eccentric  personalities  and  manic- 
depressive  insanity.    He  also  found  that  it  was  not  at  all  infrequent 


56       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

for  manic-depressive  parents  to  produce  children  with  dementia 
praecox,  while  the  reverse — namely,  manic-depressive  children 
'from  dementia  praecox  parents — belonged  to  the  rare  exceptions. 
Of  equal  significance  are  such  facts  as  the  following :  Ruedin  noted 
that  the  late  or  last-born  children  of  a  family  suffered  more  fre- 
quently from  dementia  praecox  than  the  older  children,  and  again, 
that  immediately  preceding  or  following  the  birth  of  a  praecox 
patient  there  was  frequently  a  history  of  miscarriage,  premature 
birth  or  still-birth. 

Other  facts,  the  meaning  of  which  is  unmistakable,  are  those 
presented  by  the  physical  and  psychic  stigmata  of  deviation  and 
arrest.  Saiz  places  the  frequency  of  the  physical  stigmata  at  sev- 
enty-five per  cent.  Among  the  latter  are  physical  feebleness, 
retardation  of  growth,  a  too  prolonged  juvenile  appearance,  mal- 
formations or  peculiarities  of  the  shape  of  the  skull,  deep,  narrow 
and  irregular  palate,  persistence  of  the  intermaxillary  bone,  abnor- 
malities of  the  ears,  fingers  or  toes,  imperfections  and  anomalies  of 
the  teeth  and  other  morphological  peculiarities. 

It  may  be  correct  to  accept  Ruedin's  inferences  as  to  the  heredi- 
tary transmission  of  dementia  praecox  as  a  recessive  quality  in 
accordance  with  Mendelian  law.  However,  the  foregoing  facts 
suggest  that  in  addition,  the  germ  plasm  may  sufYer  from  impair- 
ments that  afifect  its  general  morphological  and  biological  character 
and  profoundly  lower  its  possibilities  of  growth  and  development. 
Among  causes  which  may  thus  grossly  impair  the  germ  plasm  we 
have  reason  to  believe  are  infections  and  intoxications  affecting  the 
parent.  Pilcz,  Klutschefif  and  others  have  published  suggestive 
statistics  as  to  the  frequency  of  syphilis  in  the  parents,  while  Diem, 
Fuhrmann,  Ruedin,  Wolfsohn  and  others  have  published  studies 
on  alcoholism  in  the  parents  alike  suggestive  and  significant.  That 
syphilis  plays  a  role  in  a  not  inconsiderable  number  of  cases  is 
proven  by  the  frequency  of  the  Wassermann  reaction  in  the  patients 
themselves.  Bahr,  for  instance,  found  it  in  so  large  a  proportion 
as  32.1  per  cent.  Such  facts  do  not  mean  that  the  patients  are 
necessarily  suiTering  from  a  syphilitic  disease  of  the  nervous  sys- 
tem, but  rather  that  the  organism  as  a  whole  has  been  hampered, 
made  deviate  and  degenerate  in  its  development  by  the  presence 
of  the  spirochete  and  its  toxins,  i.e.,  that  the  development  of  the 
organism  as  a  whole — and  included  in  this  the  development  of  the 
glands  of  internal  secretion — has  been  so  inhibited  and  altered  that, 
at  a  given  point  of  its  life,  the  organism  breaks  down  by  reason  of 


THE  AMRRIC.IN  CONGRESS  OX  IXTERNAL  MEDICINE        57 

an  abnormal  and  toxic  metabolism.  Again,  it  is  not  necessary  that 
the  Wassermann  or  other  tests  should  yield  a  positive  result.  It 
suffices  if  the  infection  has  damaged  the  germ  plasm  of  the  parent, 
and,  in  keeping  with  this  is  the  fact  that  clinical  evidences  of  inher- 
ited syphilis  are  absent  in  the  great  mass  of  cases.  Finally,  that 
alcohol  damages  the  germ  plasm  of  the  parent  must,  I  think,  be 
freely  conceded  and  its  discussion  need  not  detain  us  here. 

The  question  whether  other  poisons  and  infections  also  play  a 
role  in  causing  damage  to  the  germ  plasm  cannot  be  definitely  an- 
swered ;  but  such  action  is  neither  impossible  nor  improbable.  In 
any  event,  however,  their  action  must  be  vastly  less  important  than 
that  of  syphilis  or  alcohol. 

It  may  be  possible,  let  us  repeat,  that  the  germ  plasm  may  be 
laden  with  a  direct  tendency  to  the  development  of  dementia  prae- 
cox,  and  which  tendency  is  transmitted  as  a  recessive  quality,  but 
that  the  germ  plasm  may  also  suffer  gross  impairments,  the  results 
of  syphilis  and  alcohol  and  perhaps  other  infections  and  intoxica- 
tions must,  I  think,  be  frankly  admitted.  Further,  in  keeping  with 
this  view  is  the  fact  that  dementia  praecox  presents  itself  not  as  a 
specific,  a  sharply  delimited  clinical  entity,  but  as  a  group  of  mental 
afifections  which  possess  the  one  common  factor  of  endogenous 
deterioration. 

The  above  considerations  point  clearly  to  the  involvement  of  the 
organism  as  a  whole.  We  should  remember,  too,  that  the  exist- 
ence of  the  various  evidences  of  morphological  deviation  visible  to 
clinical  observation  also  imply  that  other  and  perhaps  more  fun- 
damental deviations  are  present  in  the  organism  throughout.  Such 
an  organism  must  present  not  only  abnormalities  of  structure,  but 
also  abnormalities  of  function  and  especially  of  metabolism.  That 
the  internal  secretions  play  a  role  in  the  general  disturbance  is 
extremely  probable.  Dr.  Sajous  has  pointed  out  the  cogent  facts 
indicating  an  important  role  played  by  the  thymus  gland.  In  keep- 
ing with  the  view  he  has  presented  are  not  only  the  facts  pointing 
to  a  defective  nervous  development,  but  also  the  observations  of 
Barbo  and  Haberkandl  of  the  occurrence  of  osteomalacia  in  demen- 
tia praecox.  However,  I  believe  that  we  should  be  very  careful 
in  drawing  our  conclusions.  Various  facts  point  to  other  structures 
as  well.  Thus,  that  the  thyroid  gland  may  present  abnormalities 
is  a  matter  of  common  knowledge.  Occasionally  it  is  enlarged, 
more  frequently,  in  my  own  experience,  it  is  small.  Thus,  in  seven 
of  my  own  autopsies  in  which  the  thyroid  gland  was  weighed,  five 


58        THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

were  little  more  than  half  the  normal  weight,  one  was  one-fourth 
the  normal  and  only  one  approximated  the  normal.  Again,  out  of 
eight  pairs  of  adrenal  glands  five  were  greatly  in  excess,  one  de- 
cidedly below  normal  and  two  about  normal.  Such  facts  as  these 
are,  of  course,  impossible  of  detailed  explanation;  they  merely  point 
to  a  disturbance  of  the  internal  secretions.  Changes  in  the  glands 
of  internal  secretion  were  also  found  by  Farrant.  By  far  the  most 
detailed  study  of  the  weight  of  the  ductless  glands  in  the  insane  is 
that  made  by  Kojima  in  the  pathological  laboratory  of  the  Clay- 
bury  Asylum.  As  far  as  can  be  gathered  from  his  tables,  his  results 
are  practically  in  accord  with  my  own,  for  the  cases  labeled  insani- 
ties of  adolescence  and  dementia  praecox. 

The  thymus,  pituitary  and  parathyroid  glands  studied  by  Ellis 
and  myself  did  not  reveal  changes  capable  of  interpretation,  though 
here  and  there  the  findings  suggested  pathological  conditions.  Of 
our  thyroid  glands  three  out  of  the  seven  showed  changes  in  the 
colloid  material  and  four  regressive  changes  in  the  acinar  cells. 
The  most  constant  findings  in  the  adrenal  picture  was  the  small 
amount  of  fat  in  the  cells  of  the  cortex;  possibly  this  indicated  a 
lessened  functional  activity.  However,  that  there  are  other  glands 
which  probably  play  a  role  in  dementia  praecox,  the  evidence 
strongly  indicates.  Clinically  our  attention  is  strongly  attracted  to 
the  sex-glands.  We  are  confronted  by  the  anomalies  of  menstrua- 
tion, or  by  the  delayed  and  imperfect  establishment  of  puberty,  on 
the  one  hand,  or  of  sexual  precocity  on  the  other.  Again,  there  is 
the  history  of  sexual  excesses,  sexual  vagaries  and  perversions.  A 
relation  to  the  sex  glands  is  further  indicated  by  the  accentuation 
of  symptoms  often  observed  during  a  menstrual  epoch  and  by  the 
fact  that  dementia  praecox  now  and  then  has  its  incidence  in  a 
pregnancy  or  in  repeated  pregnancies  or  in  a  miscarriage,  as  though 
sex  gland  exhaustion  played  a  role.  Various  writers,  among  them 
Tsisch,  Lomer  and  Kraepelin,  have  assigned  an  importance  to  the 
sex  glands.  Lomer,  particularly,  indicated  a  disturbance  of  the 
internal  secretion  of  the  latter,  but  it  remained  for  Fauser  to  throw 
an  especially  illuminating  light  on  the  subject.  Fauser,  as  is  doubt- 
less well  known  to  my  hearers,  found  in  the  serum  of  dementia 
praecox  cases,  defensive  ferments  against  the  sex  glands  and 
against  the  cortex.  It  would  appear  from  Fauser's  investigations 
that  in  dementia  praecox  a  primary  dysfunction  of  the  sex  glands 
leads  to  the  entrance  into  the  blood  of  unchanged  sex  gland  pro- 
tein, and  that  in  the  subsequent  breaking  up  of  this  protein,  sub- 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        59 

stances  are  formed  which  are  injurious  to  the  cortex,  and  which 
bring  about  the  destruction,  the  lysis,  of  the  latter.  The  substance 
which  enters  the  circulation  is  the  internal  secretion,  the  hormone 
of  the  sex  gland,  not,  of  course,  the  germinal  product.  The  blood 
of  male  dementia  praecox  cases  digests  testicle  only,  not  ovary ; 
that  of  female  cases,  ovary  only,  not  testicle.  Fauser's  results  have 
been  confirmed  by  a  large  number  of  investigators,  among  them, 
Roemer,  Bundschuh,  Kafka,  Ahrens,  W.  Mayer,  Neue,  J.  Fischer, 
and  many  others.  Only  in  dementia  praecox  cases  could  Fauser 
demonstrate  defensive  ferments  against  the  sex  glands.  In  cases 
in  which  a  digestion  of  the  sex  glands  was  unexpectedly  found,  and 
in  which  a  diagnosis  had  previously  been  made  of  manic-depressive 
insanity  or  of  other  functional  psychoses,  the  further  clinical  course 
of  the  cases  proved  that  they  were  really  cases  of  dementia  praecox 
and  that  the  serologic  diagnosis  had  been  the  correct  one.  In  a 
number  of  less  definite  cases  of  dementia  praecox  in  which  defen- 
sive ferments  against  the  sex  glands  were  found  only  at  times,  it 
seemed  as  though  this  dysfunction  ran  parallel  with  fluctuations 
in  the  clinical  course.  In  some  cases,  again,  in  a  terminal  and  sta- 
tionary condition ;  that  is,  in  cases  in  which  the  pathologic  process 
had  run  its  course,  no  defensive  ferments  were  found  against  either 
the  sex  glands  or  cortex.  Not  infrequently,  defensive  ferments 
were  also  found  against  the  thyroid  and  against  the  adrenals. 
Ludlum,  of  Philadelphia,  has  also  obtained  positive  results  in  the 
thymus.  In  the  cases  which  reacted  to  thymus  the  patients  were 
small,  light  of  build,  and  presented  morphological  features  of  arrest 
and  other  abnormalities.  He  regards  them  as  cases  of  under- 
activity of  the  thymus.  Whatever  the  future  may  reveal,  there 
appears  to  be  no  escape  from  the  conclusion  that  in  dementia  prae- 
cox there  is  a  deranged  metabolism,  an  autotoxic  state,  in  which 
abnormalities  of  the  internal  secretions  play  a  leading  role. 

It  is  very  probable,  further,  that  in  dementia  praecox  toxic  ac- 
tion is  not  limited  to  the  cortex.  Many  of  the  symptoms  suggest 
the  action  of  toxins  upon  the  sympathetic  and  autonomic  nervous 
systems  as  well.  How  the  latter  react  to  poisons,  e.g.,  the  various 
alkaloids,  atropin,  pilocarpin,  morphin,  etc.,  is  more  or  less  defi- 
nitely known.  Our  knowledge  likewise  extends  to  the  action  of 
the  internal  secretions,  though  here,  as  a  matter  of  fact,  our  knowl- 
edge is  less  complete.  Much  information  is,  however,  in  our  pos- 
session. Adrenalin,  for  instance,  induces  contraction  of  the  blood 
vessels,  acceleration  of  the  heart's  action,  dilatation  of  the  pupils. 


60       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

drying  of  the  mucous  membranes,  lessening  of  the  secretion  of  the 
salivary  glands  and  lessening  of  the  motility  and  secretions  of  the 
stomach  and  intestines.  Similarly  the  action  of  the  thyroid  and 
pituitary  secretions  are  attended  by  phenomena  that  can  only  be 
explained  by  their  action  upon  the  autonomic  or  sympathetic  sys- 
tems. For  instance,  how  full  doses  of  thyroid  preparations  accel- 
erate the  heart's  action,  increase  the  secretion  from  the  skin  and 
of  the  intestinal  tract  and  increase  peristalsis,  and  how  markedly 
pituitary  preparations  influence  the  rate  of  the  heart,  blood  pres- 
sure and  other  processes  is  also  well  known.  That  some  of  the 
phenomena  observed  in  cases  of  dementia  praecox  are  referable  to 
mere  quantitative  increase  or  decrease  of  the  various  internal  se- 
cretions, and  that  others  still  are  due  to  perversions  of  these  secre- 
tions is  extremely  probable.  That  phenomena  pointing  to  the  action 
of  toxins  on  the  sympathetic  and  autonomic  nervous  systems  are 
present  in  dementia  praecox  cannot  be  denied.  There  are  the  phe- 
nomena presented  by  the  circulatory  apparatus,  the  digestive  tract 
and  such  other  very  special  forms  of  apparatus  as  the  iris.  In  the 
recognition  of  the  facts  lies  the  explanation  of  many  of  the  symp- 
toms. Among  the  latter  are  the  atonic  indigestion,  the  constipation 
and  the  dryness  of  the  digestive  tract,  the  phenomena  presented  by 
the  circulation,  the  alterations  of  cardiac  rhythm,  the  fall  of  blood 
pressure,  the  lividity,  dryness,  moisture,  or  other  conditions  of  the 
body  surface,  the  dilatation  or  other  anomalies  of  the  pupil ;  and 
other  symptoms  as  well.  The  point  which  should  be  emphasized 
is  that  these  phenomena  must  be  referred  to  a  toxic  action,  an 
action  which  expresses  itself  through  the  autonomic  or  sympathetic 
nervous  systems.  The  last  mentioned  fact  acquires  additional  sig- 
nificance in  our  studies  in  mental  disease,  when  we  reflect  that  it  is 
through  this  system  that  the  emotions,  the  affects,  mainly  find 
physical  expression. 

It  would  appear  that  in  dementia  praecox  the  various  glands  of 
internal  secretion  have  suffered  in  the  course  of  the  development 
of  the  organism,  so  that  their  respective  functions  are  subsequently 
imperfectly  and  aberrantly  performed.  It  is  not  at  all  unlikely  that 
while  a  number  of  glands — perhaps  the  entire  chain — are  involved 
in  most  cases,  certain  glands  by  their  action,  e.g.,  the  sex  glands, 
may  dominate  the  picture ;  in  others  again  it  is  the  thymus ;  in  still 
others  it  is  the  system  of  the  pituitary,  thyroid  and  adrenals.  In 
favor  of  the  special  role  played  by  the  thymus  is  perhaps  the  fact 
that  cases  of  dementia  praecox  frequently  betray  in  childhood  the 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        61 

forerunners  of  the  affection.  Kraepelin  states  that  very  frequently, 
especially  in  the  case  of  male  patients,  it  was  brought  to  light  that 
as  children  the  patients  had  been  markedly  quiet,  shy,  retiring,  had 
formed  no  friendships,  had  lived  only  for  themselves.  Again,  es- 
pecially in  girls,  accounts  were  received  of  irritability,  nervousness, 
stubbornness  and  obstinacy.  Then,  again,  a  smaller  group  was 
noteworthy,  mostly  boys,  in  which  the  children  were  lazy,  disliked 
work,  were  unsteady,  prone  to  misdemeanors,  held  to  nothing  and 
finally  became  tramps  and  vagabonds.  In  contrast  to  these  are 
others,  likewise  more  frequently  met  with  in  boys,  who  as  children 
are  characterized  by  docility,  good  nature,  great  conscientiousness 
and  diligence,  are  unusually  good  and  who  hold  themselves  aloof 
from  all  improper  conduct.  It  is  not  difficult  to  correlate  the  re- 
serve and  obstinacy  with  the  later  appearing  symptom  of  negativ- 
ism ;  the  oddities  and  eccentricities  with  the  subsequent  symptom 
of  impulsivity,  and  the  docility,  on  the  other  hand,  with  the  subse- 
quent symptom  of  automatism  at  command.  It  would  appear, 
indeed,  that  frequently  the  character,  demeanor  and  conduct  of  the 
child  foreshadow  the  later  appearing  symptoms  of  the  dementia 
praecox  and  that  the  affection  really  has  its  inception  in  childhood. 
It  should  be  added  in  concluding  that  it  cannot  be  inferred  from 
Kojimas  studies  that  the  changes  found  in  the  glands  of  internal 
secretion,  e.g.,  the  abnormalities  in  their  weights,  are  characteristic 
for  any  form  of  mental  disease.  However,  it  must  be  remembered 
that  Kojima  did  not  study  the  thymus. 

DISCUSSION  : 

Dr.  Harlow  Brooks,  of  New  York:  I  am  going  to  pick  out  a 
single  phase  of  this  topic  which  has  been  interesting  me  lately  and  on 
which  I  have  been  doing  a  bit  of  work,  and  that  is  the  role  which  the 
ductless  glands  apparently  play,  and  I  believe  do  play  in  the  picture 
of  collapse  which  develops  so  frequently  in  the  infections.  A  group 
of  cases  have  formed  the  basis  for  this  study,  and  since  these  cases 
have  come  into  my  service,  I  have  experimentally  reproduced  the 
condition  in  animals,  which  I  consider  a  very  much  less  important 
fact  than  the  clinical  observation  and  clinical  study.  In  brief,  my 
deductions  are,  that  in  many  of  the  infections,  particularly  in  in- 
fluenza, in  aggresive  types  of  tuberculosis,  especialy  those  which 
are  characterized  by  a  high  toxic  temperature  and  many  other 
similar  diseases,  but  notably  in  those  two,— also  one  may  put  pneu- 


^2       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

monia  in  this  class, — the  collapse  which  takes  place  so  unexpectedly 
and  so  suddenly  and  oftentimes  so  fatally,  is  due,  not  to  what  I 
supposed  it  to  be  due  in  the  past,  namely  a  degenerative  process  in 
the  heart  muscle,  but  a  degenerative  change  in  the  adrenal  tissue. 
You  all  know  who  have  worked  in  the  histology  of  this  gland  how 
difficult  it  is  to  form  a  just  idea  of  the  changes  that  have  taken 
place  because  of  the  great  facility  with  which  infarcts  occur,  espe- 
cially in  the  cytoplasm  of  the  adrenal  cell.  I  have  tried  to  bear 
that  well  in  mind,  but  in  certain  instances  there  can  be  no  question 
as  to  the  lesion,  and  therefore  we  feel  no  question  whatever  as  to 
the  clinical  signs  which  appear  as  a  result  of  this  lesion.  A  very 
brief  exposition  of  the  clinical  signs  would  be  a  circulatory  collapse 
mostly  manifested  by  a  very  marked  hypotension,  and  where  it 
occurs  in  hypotensive  cases,  it  is  marked  by  a  fall  of  pulse  pressure 
rather  than  a  fall  in  pressure  as  a  whole ;  that  is,  a  drop  in  the  sys- 
tolic pressure,  while  the  diastolic  pressure  remains  stationery. 
Another  evidence  of  circulatory  collapse  is  very  great  tachycardia  or 
bradycardia..  Those  instances  in  which  tachycardia  develops  we  have 
been  taught  to  think  are  those  in  which  there  is  an  associated  defect 
in  the  secretion  of  the  thyroid,  and  we  believe  that  observation  of 
this  apparent  effect  has  substantiated  our  theory.  The  mental, 
the  psychic  depression,  and  the  changed  clinical  picture  of  the 
case,  is  another  very  striking  feature  of  these  cases  of  sudden  cir- 
culatory collapse  which  appear  in  these  complications  of  the  in- 
fections. We  believe  that  we  have  relieved  these  symptoms  notably 
by  the  artificial  administration  of  the  gland  which  we  believe  to  be 
at  fault.  I  see  one  member  here  present  who  I  know  has  done  a 
great  deal  of  work  in  this  field — Dr.  Diner — and  who  could  speak 
from  direct  evidence  as  to  these  facts. 

Another  clinical  fact  to  which  I  wish  to  call  attention,  is  that 
when  one  substitutes  the  apparently  defective  secretion  of  these 
glands  by  the  artificial,  in  these  instances  of  collapse,  the  action 
of  our  longer  recognized  heart  stimulant  drugs,  such  as  digitalis, 
camphor,  caiifeine  and  strychina  on  the  heart  muscle,  is  much  more 
evident.  For  example,  in  cases  in  which  you  have  given  large  doses 
of  digitalis  without  much  eiTect,  if  the  adrenalin  secretion  is  added, 
a  good  effect  from  the  digitalis  immediately  appears.  Such  also 
is  true  of  caffeine  and  strychnia,  I  believe,  although  I  think  we 
must  recognize  now  that  strychnia  is  not  in  itself  a  true  cardiac 
stimulant ;  but  it  is  at  least  a  muscle  excitant,  and  as  such,  when 
used  in  connection  with  nature's  method  of  stimulating  the  circu- 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        63 

lation,  can  certainly  produce  a  much  better  effect  than  when  used 
alone. 

Dr.  Smith  Ely  Jelliffe,  of  New  York:  In  casting  about  for 
a  thought  with  which  I  might  introduce  what  I  have  to  say,  I 
picked  up  a  copy  of  Galen  on  the  "Natural  Faculties"  just  before 
I  went  to  sleep  last  night,  and  my  mind  lit  upon  the  following 
phrases.     In  the  introduction  I  find: 

"If  Galen  is  looked  on  as  a  crystallization  of  Greek  medicine, 
then  this  book  may  be  looked  on  as  a  crystallization  of  Galen. 
Within  its  comparatively  short  compass  we  meet  with  instances 
illustrating,  perhaps,  most  of  the  sides  of  this  many-sided  writer. 
The  natural  faculties  therefore  form  an  excellent  prelude  to  the 
study  of  his  larger  and  more  specialized  works.  What  now  is 
this  nature  or  biological  principle,  upon  which  Galen,  like  Hippi- 
crates,  bases  the  whole  of  his  medical  teaching,  but  which,  we  may 
add,  is  constantly  overlooked,  if  it  be  ever  presently  apprehended 
by  many  physiologists  of  the  present  day?  By  using  these  terms 
Galen  meant  simply  that  when  we  deal  with  a  living  thing  we  are 
dealing  primarily  with  a  unity,  which  while  living  is  not  further 
divisible,  and  the  parts  can  only  be  understood  and  dealt  with  as 
being  in  relation  to  this  principle  of  unity.  Galen  was  thus  led  to 
criticise  with  considerable  severity  many  of  the  medical  and  sur- 
gical specialists  of  his  time,  when  acting  on  the  assumption,  implicit 
if  not  explicit,  that  the  whole  was  merely  the  sum  of  its  parts,  and 
that  if  in  an  ailing  organism,  these  parts  were  treated  each  in  and 
for  itself,  the  health  of  the  whole  organism  could  in  this  way  be 
eventually  restored.  Galen  expressed  this  idea  of  the  unity  of  the 
organism  by  saying  that  it  was  governed  by  phusos  or  nature,  w^ith 
whose  faculties  or  powers  it  was  the  province  of  physiology  to  deal, 
and  it  was  because  Hippocrates  had  a  clear  sense  of  this  principle 
that  Galen  called  him  master.  'Greatest'  say  the  Moslems,  'is 
Allah,  and  Mohammed  is  his  prophet.'  Never  did  Mohammed 
more  zealously  maintain  the  unity  of  the  Godhead  than  Hippocrates 
and  Galen  the  unity  of  the  organism." 

So  that  in  approaching  the  subject  of  dementia  precox  I  wish  to 
emphaisze  the  unity  of  the  organism.  We  have  to  consider  all  the 
chemical  parts  of  that  organism,  but  it  is  not  the  whole  organism, 
by  any  maner  of  means.  In  fact,  it  is  an  incommensurably  small 
part  of  the  organism.  I  trust  that  you  will  pardon  me  if  just  for  a 
moment   I   attempt   to  throw  you   into  an   evolutionary   mode   of 


64       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

thinking,  to  realize  how  from  countless  ages  of  the  past,  life  has 
been  accumulating  experience — geologists  tell  us  perhaps  for  a  hun- 
dred million  years — and  little  by  little  in  that  accumulation  of  ex- 
perience life  has  been  constructing  structural  means  by  which  to 
manage  the  energy  which  is  pouring  in  upon  it.  Man,  we  know, 
is  the  last  word  in  that  series  of  experiments.  He  no  longer  handles 
the  immense  amount  of  energy  which  is  streaming  in  upon  him  by 
purely  chemical  laws.  It  was  not  possible  for  crystals  to  handle 
the  new  accumulating  amount  of  experience  in  the  past,  and  there- 
fore crystals  developed  into  a  form  of  super-chemisms  or  vital 
reactions  which,  as  we  well  know,  was  preserved  through  the  func- 
tion of  colloids.  Neither  when  the  recations  became  concentrated 
into  reflex  structures,  was  the  reflex  sufficient,  even  though  struc- 
turally very  good,  to  handle  the  accumulated  experiences.  Millions 
of  years,  millions  of  impending  forces  were  gradually  finding  an 
expression  in  men,  and  therefore  he  had  to  construct  something 
else ;  and  when  man  arose  from  lower  types,  a  new  type  of  adapter 
of  energy  arose;  and  that  new  type  of  adapter  of  energy  we  call 
the  Symbol.  So  then  man  represents,  now  as  he  is,  this  trans- 
former of  energy.  He  is  not  a  Leyden  jar.  He  is  a  transformer. 
He  has  more  than  the  ordinary  five  avenues  which  our  kinder- 
garten teaches  about  the  senses.  Comparative  histology  has  taught 
us  that  we  have  twenty-five  or  twenty-six,  and  maybe  fifty  or  more, 
receptors  for  receiving  all  of  the  various  types  of  energy  about  us, 
and  in  the  reception  of  these  types  we  must  adapt  ourselves  to 
unity  of  purpose — which  is  what?  Solely  not  for  feeling;  solely 
not  for  feeling  and  moving;  but  for  feeling  and  moving  with  our 
fcllozv  men.  So  that  through  the  necessity  of  the  social  adaptation, 
all  of  the  various  contrivances  which  finally  became  concentrated 
in  the  structure  of  man,  were  finally  adopted  and  adapted.  This  is 
the  unity  of  which  I  speak.  That  type  of  concept  which  fails  to 
recognize  the  social  purposes  of  the  individual,  which  fails  to  recog- 
nize the  reflex  activities  of  the  individual  and  only  looks  upon  the 
physicial-chemical  reactions  of  the  individual,  is  never  going  to  ex- 
plain any  disease.  If  this  is  so,  it  does  not  mean,  by  any  manner 
of  means,  that  we  must  turn  our  back  upon  these  chemical  reactions, 
these  vegetative  level  disturbances  which  have  been  called  to  our 
attention.  There  are  a  great  many  of  them,  as  we  know.  They 
have  been  called,  in  dementia  precox,  the  somatic  or  sensible  signs 
of  dementia  precox.  They  are  numerous.  The  blood  shows  a  num- 
ber of   changes — changes   in  viscosities,   changes   in   hematopoietic 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        65 

activity,  changes  in  the  amount  of  red  cells,  changes  in  the  amount 
of  the  white  cells,  changes  in  the  exudative  activity  of  the  blood 
vessels,  changes  in  the  volume  of  liciuid,  and  so  forth,  all  of  which 
have  been  studies  in  relation  to  the  vegetative  control  of  the  blood 
vessels  in  dementia  precox.  Rut  what  is  the  picture?  The  picture 
is  the  same  for  the  blood,  the  bones,  the  blood  vessels,  the  [jancreas, 
the  thymus,  the  gonads,  the  thyroid,  the  stomach,  the  intestines. 
To  every  organ  we  can  apply  precisely  the  same  reasoning.  In 
other  words,  an  enormous  amount  of  disharmony  in  the  results. 
There  is  no  harmony  in  the  results  of  any  single  series  of  investi- 
gations that  have  been  made.  Does  that  mean  they  are  of  no  use? 
Not  at  all.  They  are  all  facts.  But  it  simply  means  that  we  have  to 
use  a  truer  series  criterita  for  estimating  the  value  of  the  facts. 
The  counting  of  them  is  one  thing.  The  estimation  of  their  value 
is  another.  So  that  when  we  are  told,  as  we  have  been  told 
this  afternoon,  that  there  is  always  increased  lymphocytosis  in 
dementia  precox,  we  say  that  it  is  not  so.  And  so  one  finds  through 
at  least  a  thousand  diiTerent  studies — there  are  at  least  a  thousand 
different  studies  on  the  disordered  vegetative  mechanisms  that  are 
found  in  dementia  precox — this  enormous  disparity  results.  What 
does  it  all  mean?  It  simply  means,  so  far  as  I  can  see,  that  it  only 
represents  a  series  of  results,  reactions,  not  causes.  They  are  re- 
sults of  a  number  of  types  of  activities  on  the  part  of  the  individual, 
they  are  reactions  to  the  social  adaptation  which  comes  through  his 
psychological  processes.  Now  that  does  not  mean,  by  any  manner 
of  means,  that  dementia  precox  is  a  purely  psyschological  disorder, 
any  more  than  it  means  that  it  is  a  purely  vegetative  nervous  dis- 
order. It  is  a  disorder  of  the  individual  as  a  whole,  simply  directed 
towards  his  adaptation  in  his  social  activities ;  and  that,  therefore, 
involves  his  symbolic  values,  his  reflex  values  and  his  hormone 
values. 

It  seems  to  me  that  we  stand  to-day  on  the  threshold  of  an  enor- 
mous opportunity,  that  enormous  opportunity  that  Dr.  Dercum  just 
mentioned  in  his  paper,  and  that  connexus  that  has  just  commenced 
to  be  established  between  actual  physiological  experiment  and  the 
result  of  the  action  of  ideas  upon  the  body:  Dr.  Dercum  has  called 
it  emotional  reactions,  but  I  have  preferred  to  call  it  the  symbolic 
reactions  of  accumulations  of  psychical  values  that  the  individual 
has  been  building  up,  and  which  are  to  express  himself  in  his  rela- 
tions to  his  fellow-men.  When  Cannon's  cat,  in  the  laboratory,  is 
brought  face  to  face  with  an  infuriated  dog,  the  symbol,  a  series 


66       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

of  reactions,  takes  place — the  ercetion  of  the  hair,  the  arching  of 
the  back,  the  raising  of  the  upper  hp.  and  finally  a  series  of  chem- 
isnis,  increased  adrenalin  content,  increased  coagulability  of  the 
blood,  etc.  We  now  have  established  for  the  first  time  the  phy- 
siological relationships  between  the  psyche,  the  symbol,  and  the  un- 
conscious accumulation  of  energy  which  expresses  itself  through 
the  vegetative  nervous  system,  of  which  the  endocrinous  glands  are 
only  a  part,  because  the  endocrinous  glands  are  under  the  control 
of  this  vegetative  nervous  system,  and  the  vegetative  nervous  sys- 
tem is  not  under  the  control  of  the  endocrinous  glands.  In  other 
words,  life  began  by  chemical  interrelationships  millions  of  years 
ago,  and  because  these  chemical  interrelationships  were  not  sufficient 
to  handle  the  problems,  living  matter  constructed  nervous  interrela- 
tionships in  order  that  quick  exchange  might  take  place  between 
all  of  the  parts  of  the  body.  The  vegetative  nervous  system,  serv- 
ing as  a  medium  of  this  interrelationship,  acts  upon  all  the  con- 
stituents of  the  body  and  brings  them  to  serve  its  purposes.  Thus 
we  can  see  the  endocrinous  glands  try  to  make  the  body  subserve 
its  purposes.  An  endocrinous  gland  disturbance,  for  instance,  is 
never  going  to  explain  why  a  patient  of  mine  says :  'T  go  up  three 
steps  and  stop."  She  is  speaking  of  going  up-stairs,  and  she  says 
in  response  to  my  inquiry,  "Why  do  you  do  that?"  "Because  if  I 
don't,  I  cannot  have  a  movement  of  the  bowels."  Now  what  does 
that  mean?  Of  course  we  know  that  it  means  something  symbol- 
ically. It  is  something  in  the  mind  of  the  individual  that  is  in- 
fluencing her  conduct.  Yes,  she  has  constipation,  too ;  I  grant  you 
that.  But  the  constipation  which  is  due  to  the  disturbance  of  her 
endocrinous  glands  is  really  the  result  of  the  series  of  ideas  in  her 
adaptations,  and  if  one  attempts  symbolically  to  find  out  what  she 
means  by  going  up  three  steps  and  what  she  means  by  not  having 
a  movement  of  the  bowels,  what  she  says  appears  not  nonsensical 
at  all ;  because  what  she  really  says,  behind  the  symbol,  is  that 
"without  sexual  intercourse  I  cannot  have  a  baby."  Well,  that  is 
perfectly  good  sense.  "Three  steps  up-stairs"  is  sexual  intercourse. 
Movement  of  the  bowels  to  her  is  "having  a  baby."  We  know  that 
her  perverted  chemisms  are  not  going  to  give  her  that  idea ;  but  we 
certainly  get  help  from  the  hypothesis  that  that  idea  could  produce 
her  perverted  chemisms.  The  cat's  perverted  chemisms  did  not 
bring  the  dog  in  front  of  her,  but  the  picture  of  the  dog  did  bring 
changes  in  the  cat's  vegetative  and  endocrinous  gland. 

If,  therefore,  we  are,  as  physicians,  interested  in  adhering  to  the 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDlLlNE        67 

Hippocratic  idea  of  the  individual,  when  we  consider  the  subject  of 
so  serious  a  malady  as  dementia  precox,  we  must  consider  the 
human  organism  in  a  three-fold  relation. 

Man  is  not  a  metabolic  apparatus  only,  accurately  adjusted  to  a 
marvelous  efficiency,  through  the  intricate  mechanistic  adjustments 
of  the  vegetative  nervous  system,  nor  is  he  solely  a  group  of  com- 
plex sensori-motor  reflexes,  making  him  a  feeling,  moving  animal — 
seeking  pleasure  and  avoiding  pain  through  such  reflexes  alone  ;  nor 
yet  is  he  exclusively  a  psychological  machine,  which,  by  means  of 
a  masterly  symbolic  control  over  the  vast  hordes  of  realities  about 
him  has  made  him  and  raised  him  above  the  lower  animals.  Man  is 
all  three,  and  not  only  the  problem  of  dementia  precox,  but  tliat  of 
any  disease  of  the  human  being  is  to  be  solved  by  seeing  him  as  a 
corelation  of  all  these  types  of  activities. 

Dr.  Robert  H.  Babcock,  of  Chicago:  My  ideas  are  hardly  yet 
crystallized  into  very  definite  notions  concerning  these  subjects  that 
have  been  discussed  this  afternoon.  I  will  say,  however,  that  my 
experience,  my  clinical  observation,  is  certainly  convincing  me  of 
the  very  important  influence  of  the  two  ductless  glands,  the  adrenals, 
and  the  thyroid,  in  the  production  of  cardio-vascular  disease.  It 
seems  to  me  that  we  cannot  differentiate  the  factors  at  work.  In 
other  words,  we  have  to  consider  that  a  good  many  factors  are  at 
work  in  their  influence  upon,  for  instance,  the  adrenals,  in  the  pro- 
duction of  arterial  hypertension,  and  I  only  speak  of  two.  I  am 
becoming  quite  an  ardent  adherent  of  Crile's  theory  of  the  influence 
of  infections  upon  the  kinetic  system,  and  in  particular  the  influence 
of  infections,  whether  focal  or  general,  upon  the  adrenals.  It  has 
seemed  to  me  that  in  a  number  of  instances  I  have  been  able  to  sat- 
isfy myself  certainly  that  infections,  frequently  focal  infections, 
were  very  important  factors  in  the  production  of  arterial  hyperten- 
sion. I  am  going  to  speak  of  just  one  other  thing.  Dr.  Sajous  has 
spoken  of  the  influence  of  protein,  the  excessive  consum})tion  of 
protein  in  the  production  of  arterial  disease.  There  is  one  [)hase 
of  that  which  it  seems  to  me  is  worthy  of  consideration;  namely, 
that  one  of  the  amino  acids  produced  in  the  digestion  of  jiroteins ; 
namely,  tyrosin,  when  acted  upon  by  the  bacillus,  aminophylus 
intestinalis  is  changed  into  tyramin.  Tyramin  increases  the  blood 
pressure  (being  in  this  regard  1/14  as  powerful  as  adrenalin)  ;  and 
we  should  not  ignore  the  ])ossible  influence  of  this  product,  this 
toxic  amin,  in  those  cases  in  which  we  find  our  jjatients  have  been 


68       THE  AMERJCAX  CONGRESS  ON  INTERNAL  MEDICINE 

undue  feeders,  and  especially  undue  consumers  of  protein  out  of 
proportion  to  the  amount  of  exercise  they  take. 

Dr.  Ernest  Zueblin,  of  Cincinnati  :  As  to  arteriosclerosis  and 
the  consequences  affecting  the  vascular  system,  we  are  all  much 
interested  in  the  new  investigations  promising  to  show  that  the  in- 
ternal secretions,  that  the  ductless  glands,  must  have  a  certain  share 
in  its  etiology.  It  is  a  very  fine  problem  to  discuss  and  I  would  only 
refer  to  a  few  practical  observations.  In  former  years  we  were 
always  taught  that  arteriosclerosis  is  always  connected  with  hyper- 
tension ;  that  sooner  or  later  we  must  encounter  a  hardening  of  the 
vessels ;  that  sooner  or  later  we  must  be  confronted  with  a  hyper- 
tension ;  but  it  seems  also  that  the  view  is  expressed  and  is  em- 
phasized that  hypertension  can  be  found  and  precede  the  disease. 
Among  my  patients  I  find  frequently  a  hypertension  which  may  be 
persistent  for  years  before  we  encounter  any  further  vascular  dis- 
turbance. It  seems  to  me  that  in  investigating  the  intestinal  func- 
tions, we  find  frequently  an  aberration  in  the  metabolism,  faulty 
utlization  of  the  proteids ;  we  frequently  find  added  to  this  trouble, 
an  indicanuria,  with  symptoms  of  toxemia,  with  autointoxication. 
By  paying  attention  to  the  input  of  proteids  and  their  metabolism 
and  utilization,  I  think  we  can  help  to  a  great  extent  the  circula- 
tion by  preventing  intestinal  stasis  and  venous  congestion,  and  so 
keeping  up  a  normal  circulatory  efficiency.  If  we  remember  that  the 
heart  depending  entirely  upon  itself  sooner  or  later  will  fail,  we 
must  be  impressed  by  the  utility  of  helping  its  function  by  prophy- 
lactic, medicinal  and  dietary  means.  It  seems  to  me,  according  to 
my  experience  with  women  patients,  that  at  certain  ages  cardiac 
dilatation  takes  place ;  that  at  the  period  of  their  menopause  their 
heart  is  apt  to  present  disturbances  as  regards  regularity  and  as 
regards  size ;  and  in  those  cases  pituitary  gland  medication  seems  to 
give  rapid  and  satisfactory  results.  The  idea  has  been  suggested 
that  perhaps  in  the  progress  of  age  we  can  have  a  sub  functioning 
of  that  gland.  Could  it  not  be  possible  that  the  pituitary  gland  dur- 
ing life  plays  an  important  role  in  the  maintenance  of  a  normal  cir- 
culation? Of  course,  discussion  as  to  the  relation  of  pituitary  sub- 
stances as  cardiovascular  stimulants  cannot  be  closed,  but  practical 
results  obtained  by  their  use  suggest  further  investigation.  It 
seems  to  me  that  probably  no  organ  is  absolutely  independent  of  the 
function  of  the  endocrinous  glands,  and  it  gives  me  pleasure  to  see 
this  discussion  directed  toward  the  relation  of  the  internal  secre- 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        69 

tions  to  the  general  circulation,  as  well  as  to  all  the  functions 
of  the  organs.  That  means  a  very  interesting,  a  very  promising  field 
for  experimental  studies  aided  by  clinical  experience,  through  tlie 
practitioner  in  internal  medicine. 

Dr.  Tom  Williams,  orW.AsmxGToN,  D.  C. :  1  think  the  contributor 
mentioned  a  very  important  principle  ;  namely,  that  one  must  look 
at  the  whole  man.  At  the  same  time,  I  fear  that  the  way  in  which 
that  was  said  may  lead  to  misapprehension  on  the  part  of  many  who 
are  not  so  well  acquainted  with  dementia  precox  as  psychiatrists 
are;  namely,  that  dementia  precox  might  be  interjireted  (and  there 
again  we  shall  fall  into  the  error  of  not  looking  into  the  whole  man) 
— as  a  psychic  disorder,  in  origin,  a  failure  of  psychic  adaptation 
because  of  defect  in  the  psychic  regulation.  If  we  interpreted  Dr. 
Jelliffe's  remarks  in  that  way — however  he  means  to  interpret  them 
— we  should  fall  into  error,  because  there  are  certain  facts  to  the 
contrary.  First,  the  familiar  experience  of  every  internist  who 
finds  failure  in  the  psychic  adaptation  known  as  delirium,  in  the 
infections  and  in  the  intoxications,  which  is  removed  when  the 
physical  agent  which  is  disturbing  the  chemical  processes  is  re- 
moved. Now  we  don't  know  what  the  disturber  of  equilibrium  in 
dementia  precox  is.  We  don't  yet  know  that  it  is  chemical  or 
vegetative  or  physical  or,  as  Dr.  Dercum  says,  a  condition  of  re- 
activity due  to  Medelian  heredity.  Even  if  that  is  true,  it  has  to  be 
explained.  Now  how  can  we  reconcile  the  fact  of  failure  of  psychic 
adaptation  with  the  recovery  from  that  failure  by  purely  physical- 
chemical  measures,  such  as  those  quoted  by  Dr.  Sajous  when  he 
spoke  of  Dr.  Ludlum's  observations ;  and  I  might  add  some  observa- 
tions which  Dr.  Holmes  has  made,  in  which  chemical  intervention 
has  removed  a  situation  of  non-adaptation,  which  we  call  dementia 
precox.  Only  by  thinking  of  the  whole  man,  thinking  of  him  as  a 
series  of  links,  a  series  of  faculties  by  which  he  is  able  to  adapt, 
then,  wherever  the  break  is  we  may  have  the  failure  of  ada])tation. 
This  may  take  the  form  in  certain  individuals,  whether  predisposed 
or  through  newly  arising  causation,  of  what  we  call  dementia  pre- 
cox. In  other  words,  in  some  failures  of  chemico-vegetative  capac- 
ity leading  to  interference  with  cerebral  metabolism,  we  may  still 
have  dementia  precox ;  but  our  intervention  in  that  case  would  be 
futile  if  it  confines  itself  to  rectification  of  the  symbolic  devices,  as 
Dr.  Jelliffe  called  them,  of  which  he  gives  a  very  speaking  example : 
for  the  patient's  disturbance  of  symbolism  there  is  not  psychic  at 


70        THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

all.  It  is  due  to  the  fact  that  this  material  apparatus  fails  to  co- 
ordinate in  what  we  call  a  healthy  w^ay  and  will  not  do  it  until  we 
rectify  the  chemical  basis  upon  which  that  cerebration  depends,  just 
as  we  do  in  the  case  of  eruptive  fevers  or  of  the  chemical  intoxica- 
tions. So  we  are  back  again  to  the  whole  man,  back  again  to  what 
Dr.  Sajous  has  said,  back  again  to  looking  not  only  at  the  basic, 
fundamental,  anabolic  chemistry  of  the  body  which  is  so  impor- 
tant in  arteriosclerosis,  but  in  looking  at  the  relation  of  the  balance 
of  the  endocrine  function  and  the  several  parts  of  the  metabolism 
and  then  considering  the  pure  psychogentic  disturbance  of  the  in- 
dividual. One  word  in  reference  to  the  psychogenetic  disturbance. 
Where  we  can  trace  cause  and  effect  between  failure  of  social 
adaptation  and  some  psychological  influence,  some  idea  disturbing 
the  emotions,  our  experience  shows  that  it  can  be  rectified  by  psy- 
chological means ;  but  our  experience  also  shows  that  in  the  condi- 
tion which  we  call  dementia  precox,  in  spite  of  the  most  assiduous 
attempts  by  psychological  means,  with  all  kinds  of  skilled  assistants, 
we  fail  to  secure  readaptation  of  the  individual.  We  have  to  have 
recourse  in  that  situation  to  physical  agencies  and  we  have  the  right 
therefore  to  infer  that  dementia  precox  is  a  disorder  of  physical 
origin,  having  nothing  to  do  with  the  psyche  proper  as  regards 
causation. 

Dr.  Francis  X.  Dercum,  of  Philadelphia  :  I  know  of  course  that 
in  diseased  mental  states  the  individual  fails  in  adaptation  to  the  en- 
vironment ;  but  why  does  he  fail  ?  Is  it  not  because  he  is  ill  ?  What 
interests  me  are  the  questions,  wdiy  is  he  ill  ?  What  is  the  nature  of 
his  illness?  Is  he  ill  because  of  a  defective  organization,  because  of 
a  defective  evolution  of  his  glands  of  internal  secretion,  because  of 
some  inherited  disease,  because  of  some  obscure  disorder  of  meta- 
bolism or  perhaps  because  of  some  as  yet  entirely  undiscovered 
pathological  condition  ?  Psychological  interpretation  of  symptoms 
may  be  interesting,  but  the  tirst  and  fundamental  fact  for  the 
physician  to  recognize  is  that  the  patient  is  ill.  Psychological  specu- 
lations are  certainly  of  far  less  value  than  studies  which  show  the 
close  relation  of  psychiatry  to  internal  medicine.  Indeed  the  closer 
psychiatry  is  brought  to  internal  medicine,  the  better  both  for  the 
patient  and  the  psychiatrist.  A  patient  is  a  patient ;  he  is  sick  in  a 
material  way.  It  is  for  us  to  find  out  what  the  matter  is  with  him, 
why  he  behaves  in  this  strange  disordered  manner.  He  does  not 
do  it  wilfully;  he  does  it  because  he  is  ill  physically.     This  is  the 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        71 

problem  it  is  our  business  to  solve.  This  problem  comes  first. 
Other  matters  may  be  interesting  and  may  lead  to  all  sorts  of  specu- 
lations and  theories,  but  never  to  actual,  enduring  results. 

Dr.  Charles  E.  de  M.  Sajous,  of  Philadelphia  :  Dr.  Daland  re- 
ferred to  the  action  of  bacteria  upon  the  vessels  themselves.  Indeed, 
we  are  taught  generally  to  look  upon  the  actions  of  toxins  and 
endotoxins  upon  the  vascular  elements  themselves.  This  point  is  a 
very  important  one  in  connection  with  the  ductless  glands.  From 
my  viewpoint,  I  doubt  whether  we  can  really  credit  to  the  toxins,  or 
to  the  endotoxins  themselves,  the  morbid  processes  that  we  find  in 
the  arteries.  When  the  ductless  glands  are  taken  into  account,  many 
facts  tend  to  show  that  it  is  really  not  the  bacillus  itself,  or  its  toxin, 
that  causes  damage  to  the  vascular  endothelium,  but  the  antibodies 
which,  while  carrying  on  their  bactericidal  function,  include  in  the 
digestive  process  this  entails,  the  endocardial  and  particularly  the 
valvular  tissues.  Briefly,  autolysis  of  these  structures  occurs  along 
with  bacteriolysis,  and  valvular  lesions  are  initiated.  A  similar 
process  affects  the  vascular  elements  when  these  contain  bacteria, 
and  the  defensive  process  is  very  active  in  digestive  power,  digestive 
ferments  being  potent  factors,  we  have  seen,  in  the  defensive 
process. 

Concerning  Dr.  Dercum's  remark  as  to  the  synchronism  of  vari- 
ous ductless  glands  in  the  morbid  process  of  dementia  precox,  I 
may  recall  that  it  is  one  of  the  features  that  I  had  previously  em- 
phasized, and  that  while  I  look  upon  the  thymus  as  the  main  factor, 
it  is  because  it  is  the  predominating  ductless  gland  in  the  morbid 
process ;  just  as  the  thyroid  predominates  in  myxedema  although 
other  glands  are  involved.  In  fact  I  may  recall  that  besides  those 
of  the  thymus,  I  enumerated  the  stigmata  of  these  various  glands 
in  the  paper  just  read. 

I  was  very  much  interested  by  the  remarks  of  Dr.  Brooks.  He  will 
find  considerable  support  in  the  second  volume  of  Internal  Secre- 
tions for  the  views  advanced. 

As  regards  the  remarks  of  Dr.  JellilTe,  I  can  only  concur  with 
the  views  expressed  by  Dr.  Dercum  and  Dr.  Williams  as  regards 
the  need  of  active  treatment  if  the  deplorable  ravages  of  dementia 
precox  are  at  all  to  be  checked. 


n       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

THE  DIAGNOSIS  OF  DUODENAL  ULCER 
By  JOHN  B.  DEAVER 

The  diagnosis  of  typical  duodenal  ulcer  should  not  present  any 
difficulty  in  view  of  the  fact  that  the  symptoms  usually  appear  in 
a  well-defined  sequence,  so  well  defined,  indeed,  that  I  should  not 
hesitate  to  diagnose  a  typical  case  from  a  history  given  by  corre- 
spondence or  over  the  telephone,  and  would  feel  perfectly  con- 
fident of  having  my  diagnosis  confirmed  at  operation. 

The  typical  case  history  of  duodenal  ulcer  reveals  years,  if  not 
a  lifetime,  of  attacks  of  epigastric  discomfort  after  meals,  that  is 
to  say,  a  fulness,  often  described  as  a  "blown  out"  feeling,  and 
a  gnawing,  burning  sensation,  rather  than  pain,  with  acid  eructa- 
tions, coming  on  from  two  to  six,  commonly  three  to  four,  hours 
after  meals.  This  distress  or  pain,  as  many  patients  call  it,  rarely 
appears  after  the  morning  meal,  but  comes  on  with  constant  reg- 
ularity after  the  heavier  meals  taken  at  noon  or  in  the  evening ; 
the  so-called  hunger  pain  at  night  (about  2  a.m.)  being  one  of  the 
distinguishing  features  of  the  complaint.  No  satisfactory  explana- 
tion has  as  yet  been  forthcoming  as  to  the  rationale  of  these 
hunger  pains.  Moynihan  attributes  them  to  changes  in  the  mus- 
cular activity  of  the  stomach  and  the  duodenum  stimulated  by 
changes  in  the  chemical  quality  of  the  chyme,  especially  toward  the 
end  of  digestion.  Food  relief  or  subsidence  of  pain  upon  eating 
or  taking  an  alkali  (soda)  is  another  characteristic  symptom.  The 
periodicity  of  these  attacks  with  intervals  of  complete  well-being 
is  emphasized  by  all  authorities.  Moynihan  claims  that  they  usu- 
ally occur  in  winter  and  are  the  direct  result  of  "cold."  In  my 
experience,  and  I  have  no  doubt  in  that  of  others  also,  the  spring 
and  fall  seasons,  if  any,  are  the  ones  generally  mentioned. 

The  patients  are  usually  middle-aged  males.  In  an  analysis  of 
the  latest  series  of  53  cases  of  duodenal  ulcer  operated  on  by  me 
at  the  German  Hospital  of  Philadelphia  during  the  past  year  (Jan- 
uary to  December,  19 16)  there  were  47  males,  with  an  average 
of  41.5  years,  the  youngest  being  21  and  the  oldest  63  years  of 
age.     The  average  of  the  6  females  was  36.8  years. 

The  physical  signs  consist  of  more  or  less  tenderness  and  rigid- 
ity in  the  epigastric  and  upper  right  rectus  regions.  These,  how- 
ever, are  of  secondary  importance,  as  it  is  the  history  mainly,  and 
I  may  say  exclusively,  that  counts  in  the  diagnosis  of  the  typical 
case. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        73 

Hemorrhage  from  the  bowel  or  by  mouth,  as  evidenced  by  tarry 
stools  or  by  occult  blood  in  the  vomitus,  is  usually  noted  in  about 
one-third  of  the  cases.  It  was  a  feature  in  about  one-seventh  of 
the  histories  in  this  series.  These  patients  also  show  a  low  hemo- 
globin percentage,  though  none  of  them  presented  as  low  a  count 
as  fifty  per  cent.,  noted  by   some  clinicians. 

Vomiting  is  not  considered  one  of  the  commoner  symptoms  of 
ulcer  of  the  duodenum,  but  it  was  mentioned  in  about  one-fourth  of 
our  cases. 

High  acidity,  that  is,  an  excess  of  free  hydrochloric  acid,  gen- 
erally conceded  to  be  pathognomonic  of  the  disease,  was  noted  in 
more  than  half  of  the  cases;  subacidity  and  normal  acidity  being 
about  equally  divided  in  the  remainder. 

The  motility  of  the  stomach  is  an  important  item  in  the  symptom- 
complex  of  duodenal  ulcer.  That  its  activity  is  abnormally  rapid 
is  shown  by  the  fact  that  in  a  good  percentage  of  cases  nothing 
of  the  test  meal  or  the  full  meal  is  recovered  in  the  usual  time 
when  the  stomach  is  siphoned  after  the  administration  of  the  meal. 
This  hypermotility  of  the  stomach  is  also  demonstrated  by  the  X-ray 
and  bismuth  meal ;  they  are  thus  of  confirmatory  rather  than  con- 
tributory value  in  the  diagnosis. 

Briefly  stated,  then,  we  may  say  that  epigastric  distress  three 
or  four  hours  after  meals,  relieved  by  eating  or  by  alkahs ;  high 
acidity,  hyperactivity  of  the  stomach,  and,  in  some  instances,  vom- 
iting and  hemorrhage  are  indicative  of  duodenal  ulcer,  that  is,  of 
the  typical  case.  A  correct  pre-operative  diagnosis  was  made  in 
all  but  eight  of  the  series  of  the  present  year.  In  one  instance 
stone  in  the  common  duct  was  diagnosed  in  addition  to  duodenal 
ulcer  and  both  conditions  were  found  at  operation.  They  were 
corrected  by  choledochostomy  and  posterior  gastroenterostomy,  the 
patient  making  an  uneventful  recovery.  But  the  diagnosis  is  not 
always  such  smooth  sailing.  There  is  another  variety — the  atypical 
— that  leads  us  into  troubled  waters.  This  can  perhaps  best  be 
illustrated  by  a  case  taken  from  the  series  during  the  past  year. 

Male,  aged  32  years,  gave  a  history  of  moderate  epigastric  pain 
for  one  year  past,  coming  on  three  or  four  hours  after  meals. 
The  pain  does  not  radiate;  relief  is  obtained  after  eating  or  after 
vomiting.  Of  late  the  pains  have  increased  in  severity  and  have 
been  coming  on  one-half  hour  after  meals  and  have  been  aggra- 
vated by  eating  meat.  There  is  no  longer  the  food  relief  as  at 
first,  vomiting  alone  now  affording  relief.     For  the  past  six  weeks 


74       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

the  epigastric  distress  has  been  regularly  accompanied  by  pain  in 
the  right  loin  near  the  spine,  with  radiations  down  to  the  right 
iliac  fossa.  Vomitus  of  late  has  occasionally  been  blood  streaked 
and  stools  at  times  tarry.  Urine  also  has  sometimes  of  late  been 
red.  The  patient  complains  of  frontal  headache  and  loss  of  weight, 
having  lost  fourteen  pounds  during  the  last  two  months,  but  seems 
to  be  gaining  at  the  present  time. 

Physical  examination  shows  a  pale,  sallow,  anemic  adult  male. 
Abdomen :  slight  upper  right  rectus  rigidity,  very  active  peristalsis, 
slight  tenderness  on  deep  palpation,  especially  in  the  right  loin  near 
the  spinal  column  and  over  McBurney's  point. 

At  operation  a  duodenal  ulcer  was  found  welded  together  with 
the  great  omentum,  the  hepatic  flexure  and  the  pancreas.  The 
appendix  was  bound  down  with  its  tip  in  the  subcecal  fossa.  The 
appendix  was  removed ;  a  posterior  gastroenterostomy  was  done ; 
the  duodenum  was  not  plicated. 

The  patient  left  the  hospital  in  excellent  condition  without  any 
evidence   of   gastric   disturbance. 

These  atypical  cases  more  often  simulate  appendicitis,  especially 
where  the  appendix  is  high,  than  other  conditions  from  which  they 
can  with  more  or  less  ease  be  differentiated,  such  as  gastric  ulcer, 
cholelithiasis,  cholecystitis,  chronic  pancreatitis  and  pancreatic  lym- 
phangitis. 

Chronic  appendicitis  frequently  presents  the  same  hunger  pains 
as  in  duodenal  ulcer,  hyperacidity  is  not  unusual  and  many  cases 
show  the  same  chronicity  as  in  duodenal  ulcer.  The  main  differ- 
ence between  the  two  is  the  freedom  from  discomfort  in  the  duo- 
denal ulcers  between  the  attacks,  while  in  appendicitis  the  flatulency 
and  discomfort  are  apt  to  be  constantly  present.  But  these  patients 
with  "appendiceal  indigestion"  usually  suffer  more  pain  after  cer- 
tain kinds  of  food,  especially  starchy  food  and  red  meats.  The 
pain,  however,  usually  is  not  so  severe  as  in  duodenal  ulcer  and 
radiates  downward.  The  latter  being  one  of  the  main  points  in 
the  differential  diagnosis.  In  appendicitis  exercise  frequently  in- 
creases the  local  discomfort — not  so  in  duodenal  ulcer.  In  fact, 
the  appendix  is  found  diseased  in  so  many  cases  of  duodenal  as 
well  as  of  gastric  ulcer,  that  these  latter  may  be  considered  sec- 
ondary conditions ;  that  is  to  say,  the  result  of  infection  from  some 
other  organ  with  the  evidence  strongly  in  favor  of  the  appendix 
as  the  corpus  delicti.  I,  therefore,  make  it  a  practice  to  remove 
the  appendix  in  practically  all  cases  of  gastric  and  duodenal  ulcer. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        75 

Some  authors  claim  that  it  is  almost  impossible  clinically  to  dif- 
ferentiate between  gastric  and  duodenal  ulcer,  but  it  seems  to  me 
that  there  are  enough  points  of  variation  to  enable  such  a  differen- 
tial diagnosis  to  be  made  with  some  degree  of  certainty.  In  dis- 
tinguishing between  the  two  we  may  to  some  extent  be  guided  by  the 
time  relation  of  the  ingestion  of  food  and  the  onset  of  the  symptoms. 
Although  the  chain  of  symptoms  of  duodenal  ulcer  is  said  to  be  not 
much  affected  by  the  location  of  the  ulcer,  it  is  generally  conceded 
that  the  longer  the  interval  between  the  meals  taken  and  the  ap- 
pearance of  the  pain  and  the  more  prompt  the  food  relief,  the  lower 
down  will  the  ulcer  eventually  be  found.  Therefore,  if  pain  appears 
soon  after  eating,  in  one-half  to  two  hours,  and  the  food  relief  is 
not  prompt,  we  may  logically  expect  to  find  a  gastric  rather  than 
a  duodenal  location.  Again  the  radiations  of  pain,  if  any,  in  duo- 
denal ulcer  are  usually  to  the  right,  while  in  gastric  ulcer  the  pain 
radiates  to  the  left  as  a  rule.  The  pain  also  is  apt  to  be  more 
constant  than  in  duodenal  ulcer.  Einhorn's  duodenal  bucket  has 
been  found  useful  in  some  instances  in  approximating  the  location 
of  the  ulcer  with  more  or  less  precision,  but  I  have  not  introduced 
it  as  a  routine  procedure  in  my  service  at  the  German  Hospital  of 
Philadelphia.  Vomiting  is  also  more  frequently  a  symptom  of  gas- 
tric ulcer,  as  is  also  hemorrhage,  the  latter  usually  in  the  form  of 
hematemesis,  while  in  duodenal  ulcer  it  is  more  generally  melenic. 

Cholelithiasis  presents  rather  more  difficulty,  but  care  in  taking 
the  history  will  usually  enable  the  experienced  clinician  to  forecast 
the  true  state  of  affairs.  The  diagnosis  is  oftentimes  uncertain  when 
adhesions  exist  between  the  gall-bladder  and  the  stomach  and  the 
duodenum,  or  when  the  gall-stones  have  pushed  toward  the  duo- 
denum;  hyperacidity  being  also  a  symptom  of  gall-stone  disease, 
adds  to  the  confusion.  On  the  whole,  however,  cholelithiasis  is 
marked  by  such  severe  colicky  pain  with  sudden  and  unaccountable 
onset,  and  almost  as  sudden  and  mysterious  cessation,  that  recogni- 
tion should,  as  a  rule,  be  easy.  Lavage  will  frequently  cut  short 
an  attack  of  biliary  colic,  but  has  no  influence  on  the  pain  of  duo- 
denal ulcer.  In  this  connection  ]\Ioynihan  mentions  the  gastric  crises 
of  tabes  dorsalis,  as  a  possible  source  of  error  in  diagnosis. 

Chronic  cholecystitis  very  frequently  clouds  the  diagnosis  of 
ulcer,  especially  of  the  perforating  duodenal  ulcer.  It  presents  the 
same  chronicity,  though  the  attacks  do  not  last  so  long,  the  pain, 
hyperacidity  and  flatulency  also  present  show  a  certain  degree  of 
relationship  to  food  intake,  while  not  infrequently  the  absence  of 


76       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

typical  jaundice  in  cholecystitis  and  its  presence  in  duodenal  ulcer, 
as  noted  in  several  of  our  cases,  make  confusion  worse  confounded. 

Symptoms  similar  to  those  of  chronic  pancreatitis  or  some  pan- 
creatic involvement,  such  as  pancreatic  lymphangitis,  are  not  rarely 
met  with  in  duodenal  ulcer.  This  is  not  surprising  in  view  of  the 
close  relationship  existing  between  the  duodenum  and  the  pancreas 
and  the  frequent  infiltration  of  ulcer  into  the  pancreas  itself  and 
the  close  intercommunication  between  the  pancreatic  and  the  duo- 
denal lymphatics.  For  example,  loss  of  weight  and  strength,  a 
fairly  constant  clinical  feature  of  chronic  pancreatitis,  was  recorded 
in  one-third  of  our  cases  during  the  past  year.  The  character  of 
the  pain  in  chronic  pancreatitis  is  moderate,  as  it  is  in  the  ma- 
jority of  duodenal  ulcer  cases,  and  there  is  the  same  epigastric 
oppression.  A  valuable  distinguishing  feature,  however,  is  the  ab- 
sence in  the  pancreatic  disease  of  any  definite  relation  to  eating  or 
drinking,  or  to  the  kind  of  food  taken. 

Malignant  neoplasms  of  the  intestines,  in  their  early  stages,  some- 
times simulate  the  symptoms  of  duodenal  ulcer,  but  careful  in- 
quiry will  usually  elicit  the  fact  that  the  attacks,  though  presenting 
the  same  periodicity  as  in  duodenal  ulcer,  bear  no  relation  to  food, 
neither  in  their  onset  nor  in  the  relief  of  symptoms.  In  these 
atypical  cases,  however,  nothing  short  of  incision  and  inspection  will 
enable  us  definitely  to  determine  the  nature  of  the  lesion. 

Two  cases  of  the  present  series  diagnosed  as  acute  appendicitis 
both  proved  to  be  subacute  perforating  ulcers  which  had  been  closed 
by  plastic  exudate.  A  pre-operative  diagnosis  of  chronic  appendi- 
citis in  one  instance  proved  correct,  but  an  ulcer  of  the  duodenum 
was  also  found. 

In  four  cases  a  clinical  diagnosis  of  gall-bladder  disease  was  made 
and  in  two  ulcer  of  the  duodenum  was  present  in  addition  to  the 
cholecystitis.  In  one  case  the  diagnosis  wavered  between  carcinoma 
and  ulcer  of  the  duodenum;  operation  revealed  the  latter. 

In  thus  giving  a  cursory  summary  of  the  main  diagnostic  points 
of  ulcer  of  the  duodenum,  I  may  say,  I  hope,  that  I  speak  from  a 
wide  experience.  During  the  past  six  years  I  have  treated  by  opera- 
tion four  hundred  cases  of  diseases  of  the  stomach  and  duodenum, 
of  which  two  hundred  were  duodenal  ulcers.  With  your  permis- 
sion, I  should  like  to  say  a  few  words  with  regard  to  the  treat- 
ment of  these  ulcers.  I  know  that  I  risk  incurring  the  displeasure 
of  the  internist  when  I  say  that  he  is  responsible  for  a  large  num- 
ber of  cases  of  malignant  disease  of  the  gastrointestinal  tract  by 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        77 

attempting  medical  treatment  of  these  gastric  and  duodenal  con- 
ditions for  any  prolonged  period  of  time.  It  would  take  me  too 
far  afield  to  enlarge  upon  the  likelihood  of  malignant  degeneration 
of  these  ulcers,  especially  those  of  the  stomach.  Suffice  it  to  say 
that  the  percentage  is  variously  estimated  to  be  from  thirty-five 
(my  cases)  to  seventy  per  cent,  (other  authors).  Add  to  this  the 
fact  that  in  our  latest  series  of  cases  three  specimens  of  duodenal 
ulcer  were  returned  from  the  pathological  laboratory  bearing  the 
legend  "incipient  malignancy,"  and  you  will  realize  why  I  make 
this  statement.  A  serious  and  more  frequent  menace  presented  by 
duodenal  ulcers  is  perforation  and  hemorrhage.  I  find  from  my 
statistics  that  perforation  takes  place  in  about  fifteen  per  cent,  of 
the  cases  and  that  fully  eighty  per  cent,  give  a  history  of  previous 
gastric  disturbance.  I  have  had  only  one  death  from  hemorrhage 
in  these  cases.  This  patient  refused  operation  at  the  opportune 
time  and  died  of  hemorrhage  from  the  bowel  while  still  in  the 
hospital.  At  autopsy  an  ulcer  was  found  on  the  pancreatic  side  of 
the  second  portion  of  the  duodenum. 

With  an  operative  mortality  of  3.7  per  cent,  in  the  chronic  duo- 
denal ulcers  and  only  one  death  among  forty-six  perforated  cases 
(thirty-six  recent  statistics  at  the  German  Hospital  and  ten  cases 
of  an  earlier  series),  surely  it  is,  to  say  the  least,  unjust  to  subject 
these  patients  to  the  discomfort  and  the  risk  of  recurrence  and  the 
more  serious  dangers  already  alluded  to. 

We  were  able  to  trace  about  thirty  per  cent,  of  the  cases  of  per- 
forated duodenal  ulcer  cases,  all  of  whom  reported  well  without 
return  of  symptoms ;  the  others  reported  occasionally  epigastric  dis- 
tress after  eating.  One  case  gave  a  history  of  hemorrhage  from 
the  stomach  due  to  exertion,  this  took  place  three  years  after 
operation. 

As  to  the  type  of  operation.  Incision  and  drainage  of  sub- 
diaphragmatic abscess  was  found  sufficient  in  one  of  the  perforated 
ulcer  cases,  in  all  the  others  a  posterior  gastroenterostomy  was  per- 
formed. In  thirteen  instances  this  was  the  only  procedure ;  in 
seventeen  it  was  combined  with  pylorectomy,  and  in  one  case  in 
which  there  was  also  a  gastric  ulcer  located  on  the  lesser  curva- 
ture of  the  stomach  necessitating  a  subtotal  gastrectomy.  In  ten 
cases  the  ulcer  was  invaginated  and  in  five  it  was  excised ;  plication 
of  the  duodenum  was  done  twice.  In  accordance  with  our  usual  pro- 
cedure, the  appendix  was  removed  in  all  cases,  except  where  it  had 
already  been  removed  at  a  previous  operation.     In  one  other  case, 


78       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

besides  plication  of  the  duodenum,  the  ulcer  was  invaginated.  In 
the  cases  complicated  with  cholecystitis  a  cholecystectomy  was  per- 
formed in  two  instances,  combined  with  a  choledochostomy  in  one 
case.  A  choledochostomy,  already  mentioned,  was  done  in  one  case 
with   stone   in   the   common   duct. 


THE  PROGNOSIS  OF  DUODENAL  ULCER 
By  max  EINHORN 

The  prognosis  of  a  disease  runs  parallel  with  its  therapeutic  possi- 
bilities. Progress  in  the  cure  of  a  malady  improves  its  prognosis. 
In  duodenal  ulcer  great  advances  have  recently  been  made  in  diag- 
nosis as  well  as  in  treatment.  The  outlook,  therefore,  for  patients 
suffering  from  a  duodenal  ulcer  is  nowadays  much  brighter  and 
more  favorable  than  in  former  years. 

With  regard  to  prognosis  it  will  be  well  to  divide  duodenal  ulcers 
into  the  following  groups : 

(a)  Simple  duodenal  ulcer  ; 

(b)  Duodenal  ulcer  accompanied  by  pylorospasm  and  usually  also 
hypersecretion  (alimentary  or  continuous)  ; 

(c)  Duodenal  ulcer  accompanied  by  pyloric  or  duodenal  stenosis; 

(d)  Duodenal  ulcer  with  recurrent  hemorrhages. 

(a)  Simple  duodenal  ulcer.  Here  the  usual  symptoms  are  epigas- 
tric distress  two  to  three  hours  after  meals ;  sometimes  "hunger 
pain";  long  periods  of  euphoria  alternating  with  comparatively  short 
periods  of  suffering.  Gastric  hemorrhage  or  melena  may  have 
occurred  once. 

This  group  gives  a  comparatively  good  prognosis  provided  that 
some  form  of  a  rest  cure  is  rigidly  carried  out:  rectal  alimentation 
then  von  Leube-Ziemssen  milk  diet ;  or  duodenal  alimentation ;  or 
simply  a  milk  and  egg  diet  and  rest  abed  for  about  two  to  three 
weeks.  Later  on  no  over-exertion  (physical  or  mental)  and  a  gen- 
eral hygienic  way  of  living. 

The  oftener  the  attacks  recur  the  more  doubtful  the  prognosis 
becomes  as  to  a  complete  cure  by  medical  measures.  Operative 
intervention  (gastroenterostomy  preferably  with  pyloric  occlusion) 
offers  a  pretty  good  prognosis  with  regard  to  the  future. 

(b)  Duodenal  ulcer  accompanied  by  pylorospasm  and  also  hyper- 
secretion (alimentary  or  continuous).     Severe  pains  and  frequent 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        79 

vomiting  are  here  the  chief  symptoms.  Hypersecretion  either  ali- 
mentary or  continuous  is  here  constantly  encountered.  The  gastric 
juice  is  usually  hyperacid.  When  the  pylorospasm  reaches  a  higher 
degree  slight  ischochymia  appears  off  and  on.  The  prognosis  of  this 
group  is  quite  severe  under  ordinary  methods  of  treatment  (alkalies, 
even  milk  diet).  Duodenal  alimentation  gives  a  better  prognosis. 
But  in  case  the  latter  does  not  produce  the  desired  effect  in  from 
two  to  three  weeks,  an  operation  (gastroenterostomy  with  pyloric 
occlusion)  should  be  performed.  The  latter  usually  improves  the 
prognosis. 

(c)  Duodenal  ulcer  accompanied  by  pyloric  or  duodenal  stenosis. 
Ischochymia   is  here  constantly  present.     In  cases  of  beginning 

pyloric  stenosis ;  duodenal  alimentation  and  then  stretching  of  the 
pylorus  may  be  tried.  The  prognosis  under  this  mode  of  treatment 
varies  in  different  patients.  The  condition  must  be  watched  and 
the  prognosis  made  accordingly.  Should  there  be  no  improvement, 
or  in  case  the  stenosis  is  further  advanced,  so  that  the  duodenal 
bucket  fails  to  pass  through  the  pylorus,  an  operation  (gastroenter- 
ostomy) should  be  performed.  Barring  the  dangers  resulting  from 
the  surgical  intervention,  the  result  is  here  usually  very  good,  and 
the  prognosis  accordingly  favorable.  / 

In  duodenal  stenosis,  when  situated  below  the  papilla  of  Vater, 
there  is  bile  constantly  found  in  the  stomach  or  in  the  vomitus. 
The  treatment  requires  surgical  intervention  and  the  prognosis  then 
becomes  pretty  good. 

(d)  Duodenal  ulcer  with  periodically  recurring  hemorrhages. 
In   this  group   the   main   predominating   symptom   is   a   profuse 

hemorrhage  (either  hematemesis  or  melena  or  both),  which  periodi- 
cally returns  and  endangers  the  life  of  the  patient.  An  interval 
operation  (gastroenterostomy  eventually  with  pyloric  occlusion) 
gives  the  best  results  and  renders  the  prognosis  more  favorable. 
The  latter  must,  however,  be  made  with  caution,  as  there  may  be  a 
new  hemorrhage  even  after  apparent  perfect  recovery  from  the 
operation.  In  the  latter  event  the  prognosis  becomes  doubtful  and 
worse  with  each  repeated  hemorrhage. 

In  groups  (b),  (c),  and  (d)  the  prognosis,  in  case  no  surgical 
intervention  be  undertaken,  must  not  be  made  too  favorable,  as  there 
is  a  possibility  of  perforation.  With  the  gravity  of  symptoms  the 
liability  of  this  event  increases.  Continuous  hypersecretion  and 
severe  pains  are  frequently  prone  to  perforation.  Appropriate  meas- 
ures should  then  be  taken,  in  order  to  make  the  outlook  brighter. 


80       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

THE  POSSIBLE  DEPENDENCE  OF  GASTRIC  AND  DUO- 
DENAL ULCER  IN  MAN  ON  A  DISTURBANCE 
OF  INTERNAL  SECRETIONS 

By  G.  a.  FRIEDMAN 

The  explanation  of  a  disease  is  plausible  when  the  results  of 
experimentation  and  clinical  experience  are  in  accord  with  the  find- 
ings of  the  pathologist.  However,  since  the  pathologist  has  rarely 
the  opportunities  to  investigate  the  changes  that  occur  during  the 
initial  stage  of  an  illness  when  the  pathological  lesions  are  first  being 
developed,  and  since  he  deals  in  the  majority  of  instances  with  alter- 
ations of  tissues  probably  existing  an  entire  life  time  and  conse- 
quently when  the  disease  is  most  advanced  and  the  pathological 
changes  so  vastly  modified  by  numerous  factors,  the  suggestions  as 
to  the  possible  explanation  of  the  pathogenesis  of  certain  diseases 
may  come  from  the  experimentor  and  the  clinician.  This  is  appar- 
ently true  in  regard  to  the  origin  of  gastric  and  duodenal  ulcer,  for 
lately  it  has  been  shown  that  the  experimentor  and  the  clinician 
have  been  the  real  investigators  of  this  disease,  and  have  rendered 
possible  an  explanation  of  the  common  cause  of  peptic  ulcer  in  man 
by  a  study  of  internal  secretions,  based  on  experimental  work  which 
seems  to  harmonize  with  clinical  experience. 

It  is  beyond  my  province  to  discuss  the  theories  that  have  been 
advanced  to  explain  the  pathogenesis  of  ulcer  in  man,  but  suffice  it 
to  say  that  not  one  of  the  explanations  has  been  accepted  as  the 
common  cause  of  ulcer,  and  this  may  be  seen  from  a  statement  in  a 
circular  of  the  Special  Committee  in  Germany  for  the  collective 
investigation  of  gastric  ulcer.  "The  nature  of  gastric  ulcer,"  the 
statement  reads,  "has  not  yet  been  explained,  even  if  some  have 
been  successful  in  producing  it  experimentally  with  all  its  charac- 
teristic signs.  The  etiology  of  ulcer  in  man  is  practically  unknown." 
However,  by  our  increased  knowledge  of  activity  of  endocrinic 
glands,  by  our  closer  study  of  the  anatomy  and  the  physiology  of 
the  nervous  system,  by  the  careful  investigation  and  observation  of 
cases  by  the  clinician  who  has  had  the  opportunity  of  watching  and 
studying  individuals  during  the  whole  course  of  the  disease,  both 
medical  and  surgical,  and  by  our  improved  methods  of  animal 
experimentation,  knowledge  of  real  value  has  been  obtained.  An 
attempt  is,  therefore,  made  to  explain  the  pathogenesis  of  ulcer  in 
man  from  a  different  standpoint. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        81 

Briefly  mentioned,  the  theories  that  have  been  advanced  in  pre- 
vious years,  are  the  vascular,  the  neurogenous,  the  toxic  and  the 
microbic.  Perhaps  a  few  words  should  be  said  concerning  the  neu- 
rogenous origin  of  ulcer.  It  is  a  well  known  fact  that  ulcers  or 
erosions  of  the  stomach  were  obtained  by  cutting  the  vagus  nerve, 
the  sympathetic,  or  both.  In  Lichtenbelt's'  experiments,  the  ulcers 
produced  by  vagotomy  persisted  without  tendency  to  heal,  and  on 
account  of  the  absence  of  this  tendency,  they  greatly  simulated  the 
peptic  ulcer.  Still  the  neurogenous  explanation  of  peptic  ulcer  never 
obtained  due  prominence,  probably  because  the  clinician  did  not 
appreciate  the  nervous  symptoms  found  in  individuals  afflicted  with 
ulcer,  and  because  the  pathologist  was  rarely  able  to  discover 
changes  in  the  nerves  of  his  ulcus  material.  But  we  now  know  that 
a  functional  disturbance  in  one  structure  may  produce  pathological 
changes  in  another;  and  in  seeking  the  origin  of  the  initial  lesion  in 
peptic  ulcer,  we  have  met  with  many  strong  proofs,  both  clinical  and 
experimental,  which  have  led  us  to  conclude  that  the  lesion  is  due 
to  a  functional  disturbance  of  the  nerves  supplying  the  parts 
involved.  This  functional  disturbance  of  the  nerves  may  probably 
arise  from  errors  in  internal  secretion. 

Due  to  an  irritation  arising  from  some  source  in  the  body,  prob- 
ably the  disturbed  secretions  of  the  ductless  glands,  or  produced  by 
the  injections  of  certain  substances  or  drugs  into  the  body,  stimula- 
tion of  one  of  the  nerves  leading  to  one  or  more  of  the  smaller  gas- 
tric or  duodenal  arteries,  may  develop  a  spasm  of  that  vessel  or 
cause  occlusion  of  the  vessel  by  a  spastic  contraction  of  the  muscu- 
lature surrounding  it.  The  result  from  either  of  these  possibilities 
is  an  ischemia  of  the  gastric  mucosa  supplied  by  the  vessel  involved 
and  thus,  we  have  the  initial  lesion.  Since  cardiospasm,  gastro- 
spasm,  pylorospasm,  and  hour-glass  stomach  are  known  to  exist  in 
individuals  without  the  presence  of  an  organic  lesion  as  an  ulcer,  a 
primary  irritative  state  of  the  vagus  nerve,  with  the  resulting  gastric 
muscular  spasm,  cannot  be  denied.  If  such  irritative  conditions 
arising  from  functional  disturbances  in  nerves  are  true  for  large 
areas  of  musculature,  then  it  is  probably  also  true  for  minute  areas. 

The  explanation  here  set  forth — that  of  spastic  ischemia — must 
not  be  confused  with  the  vascular  theory  by  which  an  attempt  is 
made  to  explain  the  origin  of  ulcer  as  arising  from  a  stasis  in  the 
gastric  vessels  with  the  resulting  changes  in  nutrition,  or  affliction 
of  the  blood  vessels  by  disease,  by  embolic  or  thrombotic  processes 
or  by  arteriosclerosis.    It  is  true  that  these  occasionally  cause  ulcer- 


82       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

ation,  but  they  are  by  no  means  the  common  causes.  The  theory 
that  ulcer  is  caused  by  an  irritation  of  the  nerve  leading  to  the 
smallest  vessel  causing  a  spasm  of  its  wall,  or  even  its  occlusion  by 
spastic  contraction  of  the  musculature  surrounding  it,  either  condi- 
tion leading  to  an  ischemia  of  the  mucosa  with  subsequent  ulcera- 
tion, is  favored  by  such  men  as  Lebert,^  and  recently  by  v.  Berg- 
man,^ Benecke*  and  others. 

The  organs  which  are  supplied  with  smooth  musculature  as  the 
stomach  or  duodenum,  are  under  control  of  the  vegetative  nervous 
system,  the  regulation  of  which  is  partly  independent  of  the  central 
nervous  system.  Langley  divided  this  vegetative  system  into  the 
cranial-sacral-autonomous  group,  extended  vagus,  or  the  para-sym- 
pathetic group  and  the  sympathicus  proper.  He  also  showed  that 
the  antagonistic  physiological  relation  of  both  groups  existed  not 
only  in  the  heart,  where  this  antagonism  was  most  evident,  but  was 
present  in  the  stomach  and  intestines  where,  however,  the  vagus 
fibers  caused  stimulation  of  the  smooth  musculature  and  the  sympa- 
thicus inhibition  of  peristalsis  and  secretion. 

Langley 's  well-known  teachings  of  antagonism  have  been 
strengthened  by  the  researches  of  H.  H.  Meyer^  who  showed  that 
certain  drugs  as  pilocarpin,  muscarin,  physostigmin,  and  cholin  have 
a  selective  action  upon  the  autonomous  nervous  system  and  also 
upon  the  sweat  glands.  Atropin  paralyzes  this  system.  Adrenalin, 
however,  has  been  shown  to  have  a  stimulating  effect  on  the  sym- 
pathetic nerves.  There  is  as  yet  no  known  paralyzer  of  the  sympa- 
thetic similar  to  the  action  of  atropin  on  the  extended  vagus  or 
autonomous  system. 

The  vegetative  nerve  system  supplies  the  glands  of  internal  secre- 
tion as  well  as  the  viscera.  The  stomach  is  supplied  by  the  terminal 
branches  of  the  vagus.  The  duodenum  is  largely  supplied  by  the 
sympathetic  fibers  and  by  some  of  the  vagus  fibers.  The  adrenals 
obtain  their  nerve  supply  almost  entirely  from  the  sympathetic 
through  the  splanchnic  nerve.  The  thyroid,  however,  has  a  double 
innervation,  the  sympathetic  and  the  vagus.  The  pituitary  body  may 
be  excluded  from  consideration  here  since  the  secretion  of  this  gland 
acts  upon  tissues  innervated  by  the  pelvic  nerve. 

There  now  remains  the  application  of  these  physiological,  pharma- 
cological, and  anatomical  facts  to  the  clinic  and  this  was  done  by 
Eppinger'  and  Hess,^  whose  teachings  of  vagotonia  and  sympathico- 
tonia are  well  known.  They  have  clinically  divided  patients  into 
two  groups,  the  vagotoniac  and  the  sympathicotoniac,  basing  their 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        83 

classification  upon  the  different  symptoms  arising  from  disturbances 
in  one  or  the  other  of  the  subdivisions  of  the  vegetative  system. 
By  a  vagotoniac  is  meant  an  individual  vi'ho  is  extraordinarily  sus- 
ceptible to  drugs,  stimulating  or  paralyzing  the  vagus  nerve,  as  pilo- 
carpin,  atropin.  Sympathicotoniacs  on  the  other  hand,  are  extremely 
susceptible  to  adrenalin,  the  stimulating  drug  par  excellence  of  the 
sympathetic.  The  symptoms  and  signs  belonging  to  each  clinical 
group  and  the  symptoms  produced  by  the  injection  of  the  specific 
drugs  mentioned,  have  been  well  described  and  need  not  be  men- 
tioned here.  However,  it  must  be  remembered  that  no  sharp  lines 
can  be  drawn  between  the  two  groups,  for  often  the  symptoms  over- 
lap, but  one  should  always  consider  the  symptoms  and  signs  related 
to  vagotonia  and  sympathicotonia,  as  stigmata  of  the  vegetative 
nervous  system. 

In  order  to  make  use  of  all  the  considerations  mentioned,  it  must 
be  shown  that  vegetative  stigmata  are  actually  present  in  the 
majority  of  individuals  suffering  from  gastric  and  duodenal  ulcer. 
Clinical  experience  shows  that  patients  suffering  from  chronic  pep- 
tic ulcer  may  be  divided  into  two  groups : — First,  those  in  whom  the 
organic  element  without  apparent  nervous  manifestations  is  evident. 
At  operations,  ulcer  is  usually  found.  These  patients  are  fre- 
quently benefited  by  the  various  surgical  procedures.  Secondly, 
those  in  whom  the  nervous  element  is  so  predominant  that  it  is  often 
difficult  to  eliminate  the  organic  element  as  the  chief  cause  of 
trouble.  At  operation,  ulcer  is  found,  but  usually  the  result  of  the 
operation  is  not  beneficial.  If  one  questions  these  patients  carefully 
as  to  symptoms  and  signs  regarding  the  nervous  system,  autonomic 
and  sympathetic,  he  will  often  be  surprised  as  to  the  number  of 
vegetative  stigmata  present,  even  in  the  majority  of  cases  belonging 
to  the  first  group.  The  complete  absence  of  symptoms  and  signs 
pointing  to  a  disturbed  equilibrium  of  the  vegetative  nervous  system 
may  be  mainly  noticed  in  the  fifth  or  sixth  decade  of  life.  The 
younger  the  individual  afflicted  with  peptic  ulcer,  the  more  numerous 
are  the  vegetative  stigmata.  But  even  in  old  people,  in  whom  the 
first  symptoms  of  ulcer  dates  back  twenty  or  twenty-five  years,  one 
will  elicit  the  history  of  previous  nervous  symptoms  which  may  be 
interpreted  as  evidence  of  vegetative  disturbance.  It  is  a  well- 
known  fact  that  functional  disturbances  have  a  tendency  to  disap- 
pear with  age,  though  the  organic  lesion,  the  sequel  of  such  disturb- 
ances may  remain. 

The  symptoms  and  signs  usually  found  in  cases  of  peptic  ulcer 


84       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

are  practically  similar  to  those  found  in  vagotonia  and  sympathico- 
tonia, the  underlying  causative  factor  being  the  same,  namely  a  dis- 
turbance in  the  vegetative  nervous  system.  Gastric  ulcer  cases  show 
frequently  symptoms  of  vagotonia,  duodenal  ulcer  cases  more  often 
symptoms  of  sympathicotonia.  The  chief  symptoms  elicited  in  the 
history  are: — excessive  salivation  or  dryness  of  the  mouth,  clammy 
or  dry  hands  and  feet,  a  tendency  to  perspiration,  usually  localized 
to  some  area,  as  the  axilla,  beneath  the  breasts,  etc.,  constipation 
usually  of  the  spastic  type  or  rarely  diarrhea.  Among  the  more 
important  physical  signs  and  phenomena  in  ulcer  cases  suggestive 
of  a  derangement  of  the  vegetative  system  we  find  narrow  or  wide 
pupils,  various  grades  of  protrusion  of  the  bulbi,  even  exoph- 
thalmos, absence  or  diminished  corneal  reflex,  narrow  or 
widened  polpebral  fissures,  excessive  flow  of  tears  and  glittering 
eyes,  gastric  succorhea  or  achylia,  high  or  low  gastric  acidity,  gastro- 
intestinal hyper  or  hypomotility,  spastic  or  atonic  constipation, 
bradycardia  or  tachycardia,  absence  or  exaggeration  of  gag  reflex, 
dermographia  and  Ashmer's  oculo-cardiac  reflex,  which  is  produced 
by  a  continuous  pressure  with  the  fingers  on  the  eyeball  and  noting 
the  sudden  slowing  of  the  pulse  rate,  a  sign  of  vagotonia.  In  addi- 
tion, we  can  note  in  cases  of  peptic  ulcer  the  presence  of  Stiller's 
habitus  and  as  pointed  out  by  E.  Kraus,'^  the  so-called  Blahhals,  a 
prominence  of  the  neck  due  to  an  extreme  vascularization  of  the 
thyroid  gland. 

Furthermore,  the  patients  with  peptic  ulcer  respond  to  the  pilo- 
carpin  and  adrenalin  tests.  WestphaP  and  Katsch,^°  who  have 
made  an  extensive  study  of  this  subject,  pointed  out  that  some  of 
these  patients  are  more  susceptible  to  pilocarpin  and  others  to 
adrenalin,  which  fact  proves  the  clinical  findings  of  Eppinger  and 
Hess.  Only  in  the  middle-aged  patients  they  found  frequently  that 
the  reaction  was  negative  to  either  of  these  drugs.  My  own  experi- 
ence has  taught  me  that  individuals  suffering  from  gastric  ulcer 
present  more  often  vagotonic  symptoms  and  respond  rather  strongly 
to  the  injections  of  pilocarpin,  while  those  sufifering  from  duodenal 
ulcer  show  frequently  the  sympathicotonic  symptoms  and  react 
therefore  more  often  positively  to  injections  of  adrenalin.  These 
facts  are  probably  explained  by  the  differences  in  innervation  of  the 
stomach  and  duodenum.  We  see,  therefore,  that  clinically  and 
pharmacologically  the  symptoms  and  signs  which  define  the  status 
of  the  vagotoniac  and  the  sympathicotoniac  may  be  found  in  patients 
suffering  from  gastric  and  duodenal  ulcer. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        85 

There  are,  moreover,  other  factors  which  suggest  the  dependence 
of  ulcer  on  the  derangement  of  the  vegetative  system  with  the  con- 
sequent disturbance  in  certain  ductless  glands.  Several  years  ago, 
Dr.  Lewis,  of  the  General  Memorial  Hospital,  assistant  of  Professor 
Benedict,  at  my  request,  has  examined  the  percentage  of  blood 
sugar  in  a  number  of  my  patients  whom  I  believed  had  peptic  ulcers. 
Operative  evidence  was  obtained  in  ten  of  them,  and  in  five  of  these, 
callous  duodenal  ulcer  was  found.  In  these  the  percentage  of  blood 
sugar  was  above  normal,  while  in  four  others  who  had  pyloric 
ulcers,  the  percentage  of  blood  sugar  was  below  normal.  However, 
in  the  tenth,  in  whom  ulcer  of  the  lesser  curvature  was  found,  the 
percentage  of  blood  sugar  corresponded  to  that  found  in  duodenal 
ulcer  cases. 

The  change  in  the  percentage  of  blood  sugar  is,  I  believe,  due  to 
a  glandular  disturbance.  That  the  product  of  the  secretion  of  the 
islands  of  Langerhaus  requires  the  presence  of  some  other  agent 
for  its  glycolytic  action  was  first  shown  by  Diamare,^^  and  later  by 
others.  Sajous,^^  in  1907,  suggested  that  the  secretion  of  the 
adrenal  was  the  necessary  factor  in  this  process.  This  was  further 
substantiated  by  W.  G.  MacCallum"  four  years  later. 

Secondly,  we  have  the  characteristic  differences  in  the  blood  pic- 
tures between  chronic  callous  gastric  and  duodenal  ulcers.  These 
differences  have  been  noted  and  pointed  out  by  me  in  several  of  my 
published  papers. ^■*'  ^-'^  '"'  '^-  But  the  significant  fact  is  the  resem- 
blance of  the  blood  count  in  duodenal  ulcer  to  that  of  polyglobulia 
induced  by  adrenalin  injections  and  of  the  blood  picture  in  gastric 
ulcer  to  that  found  in  hyperthyroidism.  Bertelli,'^  Falta,^^  and 
Schweeger^"  and  later  Imachnitzky-'  have  observed  an  increase  of 
erythrocytes  of  from  30  to  100  per  cent,  in  dogs  and  man  after 
intravenous  or  subcutaneous  injections  of  epinephrin  (this  experi- 
mental polyglobulia  lasting  sometimes  for  about  30  hours),  and 
they  have  also  noted  after  such  injections  a  marked  decrease  in  the 
eosinophiles.  In  my  papers  I  show  a  polyglobulia  and  an  eosino- 
penia  to  be  significant  of  duodenal  ulcer  of  the  callous  type.  The 
similarity  of  the  blood  picture  of  pyloric  ulcer  to  that  of  hyper- 
thyroidism— a  mononucleosis  and  a  relative  eosinophilia — is  also 
quite  marked.  Kocher-^  has  repeatedly  stated  that  the  mononuclear 
cells  frequently  predominate  in  Graves'  disease.  In  addition, 
Eppinger-''  frequently  found  an  increase  of  eosinophiles.  I  have 
observed  in  nearly  every  case  of  the  callous  pyloric  ulcer  an  in- 
creased number  of  small  mononuclears  and  an  increase  in  the  eosi- 


86       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

nophiles.  Although  some  state  that  in  myxodema  there  is  an  increase 
in  mononuclears,  others  believe  that  the  picture  found  in  this  con- 
dition is  not  analogous  to  that  in  Graves'  disease,  because  after  the 
administration  of  thyroidin  in  myxedema,  the  blood  picture  returns 
to  normal,  while  in  Graves'  disease  it  diverges  still  further  from 
normal.  It  should  be  mentioned  here  that  Kaufmann-*  who  made 
blood  examinations  in  a  number  of  gastrointestinal  disorders  has 
found   frequently  lymphocytoses. 

Although  we  have  recently  learned  to  associate  sympathicotonic 
and  vagotonic  symptoms  with  disturbances  in  equilibrium  of  the 
vegetative  nervous  system  and  although  we  have  seen  that  the  occur- 
rence of  ulcer  is  frequent  in  cases  of  vagotonia  and  sympathicotonia, 
there  remains  the  correlation  of  these  facts  with  disturbances  in 
internal  secretions.  It  is  well-known  that  the  vegetative  nervous 
system  is  the  regulator  of  the  glands  of  internal  secretions  as  well 
as  the  viceral  organs.  Asher-''  and  Flachs^®  have  indisputably 
shown  that  the  thyroid  gland  is  influenced  by  the  superior  and 
inferior  laryngeal  nerves.  Biedl,-'^  Dryer,-^  Tsherboksaroff-^  and 
Asher^"  have  in  addition  shown  with  absolute  certainty  that  the 
splanchnic  nerve  is  the  secretory  nerve  to  the  adrenal.  It  appears 
that  when  one  of  the  glands,  for  instance,  the  thyroid  or  adrenal, 
has  been  stimulated  by  the  vegetative  nerves  and  kept  under  its 
influence  abnormally,  there  may  be  a  reaction,  and  the  nerve  itself 
may  become  influenced  through  the  disturbed  activity  of  the  gland ; 
in  other  words,  a  vicious  circle  may  set  in  between  the  vegetative 
nerve  and  the  gland.  Since,  therefore,  a  disturbance  in  the  vege- 
tative nerve,  vagus  or  sympathetic,  may  lead  to  disturbances  in  the 
function  of  the  thyroid  or  adrenal,  and  since  there  is  a  reciprocal 
reaction  between  them,  a  minor  degree  of  disturbance  in  these  glands 
may  show  its  influence  upon  the  nerves,  and  the  result  of  such 
influence  may  become  evident  clinically,  by  pathological  changes 
in  the  structures  supplied  by  the  nerves  affected,  and  by  the  pro- 
duction of  the  symptoms  and  signs  of  vagotonia  or  sympathicotonia. 
The  mode  by  which  the  ductless  glandular  system  may  influence 
the  excitability  of  the  vegetative  nerves  is  not  quite  known,  but  it  is 
probably  produced  through  the  agency  of  hormones.  At  least  this 
has  been  established  with  certainty  in  regard  to  adrenalin,  and  it  is 
possibly  true  of  the  other  internal  secretions. 

The  vegetative  stigmata  found  in  individuals  suffering  from  pep- 
tic ulcer,  the  susceptibility  of  these  patients  to  the  administration  of 
drugs  which  have  a  selective  action  upon  the  vagus  and  sympathi- 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        87 

cus,  the  blood  picture  of  duodenal  ulcer  resembling  the  experimental 
polyglobulia  and  eosinopenia  after  adrenalin  injections,  the  blood 
picture  in  pyloric  ulcer  which  frequently  simulates  that  found  in 
hyperthyroidism,  all  these  facts  are  hardly  sufificient  to  lead  us  to  a 
conclusion  as  to  the  possible  dependence  of  ulcer  in  man  on  a  dis- 
turbance of  secretion  of  certain  ductless  glands.  Thus  far  we  know 
that  an  excess  of  adrenalin  is  circulating  in  the  blood  of  the  sympa- 
theticotoniac.  The  excess  of  secretion  which  is  supposed  to  circu- 
late in  the  blood  of  the  vagotoniac  is  not  known.  Eppinger  and 
Hess  have  named  this  hypothetical  secretion  "autonomin"  and  this 
is  supposed  to  stimulate  the  autonomous  system.  However,  since 
the  thyroid  has  two  secreting  components,  one  from  the  sympa- 
thetic and  the  other  from  the  vagus,  the  component  originating 
through  stimulation  of  the  vagus  fibers  may  be  the  one  circulating 
in  the  blood  of  the  vagotoniac.  The  experiments  of  WestphaP^ 
seem  to  hint  to  such  a  possibility.  He  first  tried  to  imitate  vago- 
tonia in  rabbits,  cats,  dogs  and  guinea  pigs  by  injections  of  pilo- 
carpin.  He  succeeded  in  producing  peptic  ulcer  of  the  stomach  in 
nearly  all  of  the  rabbits,  and  in  some  of  the  cats  and  in  dogs.  I 
have  repeated  his  experiments  on  rabbits  and  present  here  four 
specimens  showing  distinctly  peptic  erosions  after  pilocarpin  injec- 
tions. Since,  after  thyroidectomy,  as  it  has  been  proven,  pilocarpin 
had  little  effect  in  provoking  vagotonic  symptoms,  we  possibly  have 
proof  of  the  relation  rather  indirectly  of  some  component  of  the  thy- 
roid secretion  upon  the  vagus.  This  leads  me  to  mention  the  so- 
called  vagotonic  type  of  Graves'  disease.  This  has  first  been  de- 
scribed by  Eppinger  and  Hess  who  have  shown  that,  although  it  is 
generally  acknowledged  that  Graves'  disease  is  due  to  a  disturbance 
in  the  sympathetic,  there  are  definite  forms  of  Graves'  disease  with 
symptoms  and  signs  pointing  to  a  heightened  tone  of  the  vagus  ele- 
ment supplying  that  gland. 

We  became  more  convinced  that  an  excess  of  thyroid  secretion 
may  affect  the  mucous  membrane  of  the  stomach,  producing  ero- 
sions, since  in  two  dogs  and  one  rabbit  (of  four  animals  experi- 
mented upon  by  subcutaneous  and  intravenous  injections  for  about 
one  week  of  dessicated  thyroid  gland)  we  have  obtained  gastric 
erosions. 

Seeing  a  possible  connecting  link  between  the  polyglobulias  and 
eosinopenia  which  I  found  in  duodenal  ulcer  and  the  experimental 
polyglobulias  found  after  injections  of  adrenalin  on  the  one  hand, 
and  the  tendency  of  adrenalin  to  affect  tissues  innervated  by  the 


88       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

sympathetic  on  the  other,  we  set  up  the  working  hypothesis  that  the 
initial  lesion  of  duodenal  ulcer  may  be  caused  by  excessive  secre- 
tion of  the  adrenals.  With  this  object  in  view  experiments  were 
undertaken  consisting  of  repeated  injections  of  adrenalin  in  dogs. 
Since  some  of  the  experiments  described  here  have  been  fully 
published  in  two  of  my  papers,  ^-'  ■^•'■'  I  need  but  mention  them 
briefly. 

It  was  found  that  injections  of  adrenalin  administered  to  dogs 
intravenously,  subcutaneously,  or  intramuscularly  for  about  one  to 
two  weeks  in  dosages  not  exceeding  three  milligrams  of  the  usual 
commercial  solution  (i:iooo)  are  liable  to  cause  lesions,  erosions 
or  superficial  ulcerations  in  the  duodenum.  As  such  lesions  were 
found  in  the  duodenal  mucosa  in  eleven  dogs  out  of  twelve  and 
later  in  two  out  of  four  and  only  occasionally  gross  changes  were 
noted  in  other  organs,  we  concluded  that  adrenalin  might  have  a 
preferential  action  upon  the  duodenum,  probably  because  of  the 
latter's  rich  sympathetic  nerve  supply,  since  as  has  been  pointed 
out,  the  sympathicus.  resp.  splanchnicus  is  the  secretory  nerve  of 
the  adrenals.  In  normal  dogs,  autopsied  as  controls,  the  gastric 
and  duodenal  mucosa  was  found  to  be  intact.  In  looking  over  the 
experiments  with  injection  of  adrenalin,  in  rabbits  which  were 
done  previously  for  other  purposes,  we  were  surprised  to  find 
frequently  notes  of  "marked  congestion"  or  lesions  in  the  first  por 
tion  of  the  duodenum. 

After  one-sided  thyroidectomy  in  dogs  and  in  rabbits,  lesions  or 
ulcers  were  found  in  the  duodenum  more  frequently  than  in  the 
stomach.  Occasionally  ulers  were  found  in  both  viscera  or  in  the 
jejunum.  A  careful  search  in  the  literature  has  revealed  that  Carl- 
son^* and  Jacobsohn^^  have  incidentally  found  gastric  and  intestinal 
lesions  in  seventy-five  per  cent,  of  thyroidectomized  dogs.  They 
emphasize  the  fact  that  the  ulcers  were  always  most  extensive  in 
the  upper  part  of  the  duodenum. 

After  extirpation  of  both  adrenals  in  two  stage  operations  and 
after  extirpation  of  one  adrenal  in  dogs  and  in  rabbits  and  also 
later  in  cats  and  in  guinea  pigs,  lesions  or  erosions  were  frequently 
found  in  the  stomach.  In  the  duodenum  of  rabbits  and  guinea  pigs 
and  in  one  dog,  lesions  were  found  also  after  one-sided  adrenalec- 
tomy, when  the  unextirpated  adrenal  became  hypertrophied. 

Gastric  ulcers  after  exirpation  of  adrenals  were  first  produced 
by  Finzi.^®  He  also  showed  that  if  after  extirpation  of  the  supra- 
renal gland,  adrenalin  is  injected,  the  gastric  mucosa  remains  intact. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        89 

Elliot''^  produced  upon  adrenalectomy,  ulcers  in  cats,  and  recently 
Mann^*'  ^^^  in  dogs  and  in  cats. 

After  extirpation  of  one  adrenal  and  one  thyroid  lobe  of  the  same 
or  the  opposite  sides,  no  lesions  in  the  stomach  or  duodenum  were 
found  in  our  experiments. 

To  sum  up  the  results  of  my  experiments  presented  in  the 
two  communications  and  from  those  yet  unpublished,  we  have: 
I.  Adrenal  insufficiency  causes  in  various  species  of  animals,  lesions 
or  ulcers  in  the  stomach.  2.  An  excess  of  thyroid  gland,  as  pro- 
duced by  repeated  intravenous  injections,  was  probably  responsible 
for  the  gastric  lesions  in  three  animals  out  of  the  four  experimented 
upon.  3.  Thyroid  hypofunction  caused  the  appearance  of  duodenal 
and  gastric  lesions.  4.  An  excess  of  adrenalin  produced  by  repeated 
injections  of  the  drug,  led  to  appearance  of  lesions  in  the  duodenum 
of  dogs  and  rabbits.  5.  The  simultaneous  production  of  adrenal 
and  thyroid  hypofunction  did  not  lead  to  any  lesion  in  the  stomach, 
nor  in  the  duodenum  of  rabbits.  6.  When  after  removal  of  an 
adrenal  the  other  became  occasionally  hypertrophied,  lesions  were 
seen  in  both  viscera  in  rabbits. 

From  our  experiments  it  seems  probable  that  gastric  lesions  may 
be  dependent  upon  adrenal  insufficiency  as  well  as  upon  excess  of 
adrenalin.  Gastric  and  duodenal  lesions  may  be  dependent  upon 
the  alternating  efifect  of  hypo-  and  hyper- function  of  the  adrenals. 
From  all  these  considerations  a  correlation  of  secretions  of  the 
thyroid  and  adrenals  seems  to  be  plausible  in  the  causation  of  gas- 
tric and  duodenal  lesions  in  our  animals. 

For  the  sake  of  briefness,  I  have  to  omit  a  discussion,  pJresented 
in  one  of  my  papers  as  to  reciprocal  relations  between  the 
thyroid  and  the  adrenals  as  obtained  in  our  animals.  In  our 
thirty-six  thyroidectomies  performed  in  dogs  and  in  rabbits,  we 
have  never  observed  hypertrophy  of  the  unremoved  thyroid  lobe 
unless  as  happened  in  several  dogs  in  which  infection  set  in.  But 
we  did  observe  in  two  dogs  and  two  rabbits  after  parathyroidectomy 
where  parathyroids  were  not  spared,  a  marked  hypertrophy  of  the 
adrenals.  These  animals  died  from  tetany.  It  is  possible  then,  that 
after  one-sided  thyroidectomy,  the  adrenals  hyperfunctionate  with- 
out hypertrophy  and  in  consequence  duodenal  lesions  frequently 
develop  as  they  do  after  injections  of  adrenalin.  The  gastric  lesions 
after  removal  of  the  adrenals  may  be  due  to  a  hyperfunction  of 
thyroid  as  occurs  after  injection  of  dessicated  thyroid  extract. 
Although,  as  has  been  mentioned,  there   is   a   vagotonic   type   of 


90        THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

Graves'  disease,  Higier*"  believes  that  Addison's  disease  also  pre- 
sents the  best  illustrative  instance  of  a  slowly  developing  vagotonia, 
emaciation,  diarrhea,  low  blood  pressure,  and  the  reduction  or  dis- 
appearance of  blood  sugar.  In  classifying  Addison's  disease,  there- 
fore, as  vagotonia,  Higier  sees  the  abolishment  of  the  most  impor- 
tant sympathetic  impulses.  If  a  vagotoniac  type  of  Addison's  dis- 
ease is  possible,  what  should  be  our  conception  of  it?  As  Addison's 
disease  develops,  the  sympathetic  impulses  become  gradually  abol- 
ished, since  the  normal  tone  of  the  sympathetic  is  under  control  of 
the  adrenals.  With  the  double  innervation  in  the  thyroid,  the 
antagonistic  vagus  element  in  the  gland,  therefore,  hyperfunction- 
ates,  and  as  a  result  an  excessive  amount  of  thyroid  products,  the 
so-called  autonomins  of  Eppinger  and  Hess,  will  be  discharged  into 
the  circulation.  The  effect,  however,  of  this  disturbance  in  secre- 
tion, may  become  modified  by  the  presence  of  diseased  adrenals. 
Just  as  there  is  a  possible  connecting  link,  therefore,  between  vago- 
tonic exophthalmic  goiter  and  Addison's  disease,  a  somewhat  simi- 
lar correlation  might  have  developed  in  our  animals  after  removal 
of  one  adrenal  and  one  of  the  thyroid  lobes. 

We  now  turn  to  the  applicability  of  these  experiments  to  the 
clinic.  Since  vegetative  stigmata  are  found  in  the  majority  of 
patients  suffering  from  gastric  or  duodenal  ulcer,  and  since  a  dis- 
turbance of  the  equilibrium  in  the  vegetative  nervous  system  may 
lead  to  a  disturbance  in  the  secretion  of  the  thyroid  or  adrenals 
or  both,  there  is  a  possible  connecting  link  between  the  vegetative 
stigmata  and  the  appearance  of  the  initial  lesion  of  peptic  ulcer. 
Although  Eppinger  and  Hess  were  the  first  to  recognize  anomalies 
of  constitution  as  dependent  on  a  derangement  of  the  vegetative 
nerves,  it  was  Korte*^  who  originally  in  a  discussion  at  the  XXXV 
Congress  of  the  German  Society  fiir  Chirurgie  in  1906  correlated 
the  anomalies  of  constitution  with  peptic  ulcer.  He  then  expressed 
his  opinion  that  a  local  affection  of  the  gastric  mucous  membrane 
might  possibly  bear  some  relation  to  the  constitutional  anomalies, 
the  nature  of  which  was  unknown,  and  that  these  anomalies  of  con- 
stitution were  the  disturbing  factors  in  the  healing  process  of  peptic 
ulcer. 

However,  the  functional  disturbance  in  the  vegetative  sytem  must 
not  necessarily  lead  to  a  pathological  change  in  the  ductless  glands 
as  in  the  vegetative  organs.  As  often  happens,  an  organ  neurosis, 
gastric  or  intestinal,  without  organic  phenomena  may  be  the  result. 
Hence  we  may  also  assume  a  ductless  gland  neurosis  by  which  I 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        91 

mean  a  functional  derangement  of  the  nerve  supply  to  the  gland 
without  a  pathological  change  in  that  organ  or  nerve  but  leading, 
however,  to  a  disturbance  in  secretion.  Bauer,*^  Hemmeter*"*  and 
others  dealt  extensively  with  these  neuroses  of  endocrinous  glands. 
The  secretion  of  such  a  disturbed  gland  may  react  upon  the  vegeta- 
tive nerve  system  and  influence  the  system  still  more,  thus  estab- 
lishing a  vicious  circle  as  has  been  explained  previously.  Thes  fac- 
tors may  lead  to  the  anomalies  in  constitution  which  Eppinger  and 
Hess  and  Korte  have  noted,  and  may  also  produce  the  initial  lesion 
of  the  ulcer.  With  the  return  to  normal  conditions  in  the  vegetative 
nervous  system  and  in  the  glands,  the  anomalies  in  constitution  may 
disappear  but  the  ulcer,  however,  the  material  or  pathological  result 
of  all  these  disturbances,  remains,  and  may  now  proceed  to  heal. 
McCallum**  points  out  that  many  ulcers  in  man  heal  spontaneously 
as  may  be  judged  from  the  scars  at  autopsies.  All  have  seen  at 
operations  deep  scars  in  the  stomach  or  duodenum  from  healed 
ulcers.  Ulcers  heal,  therefore,  when  the  anomalies  of  constitution 
due  to  disturbance  in  the  equilibrium  of  the  vegetative  nerve  sys- 
tem, and  hence  in  the  disturbance  of  the  glands,  disappear,  but  the 
scar  is  the  witness,  however,  that  such  a  disturbance  has  existed. 
One  may  now  comprehend  why  some  patients  do  not  show  vege- 
tative stigmata  at  the  time  of  examination,  but  have  all  the  evidence 
pointing  to  an  organic  lesion,  and  why  such  patients  are  fully  bene- 
fited by  surgical  procedures. 

If  it  be  true  that  the  initial  lesion  of  peptic  ulcer  is  due  to  ano- 
malies of  constitution  then  the  occurrence  of  peptic  ulcers  in  the 
newborn  and  in  young,  may  be  explained  as  congenital — that  is  to 
say  the  inheritance  of  the  anomalous  condition.  Huber*^  has  made 
a  special  study  of  the  occurrence  of  peptic  ulcer  in  several  members 
of  many  families.  He  came  to  the  conclusion  that  the  occurrence 
is  not  rare.  I  have  under  observation  a  girl  with  gastric  ulcer 
whose  mother  was  operated  for  gastric  ulcer  one  year  ago.  I  am 
almost  certain  that  the  more  we  question  our  patients  in  regard  to 
inheritance,  the  more  frequently  will  we  discover  the  presence  of 
the  ulcer  running  in  the  same  family. 

There  is  no  doubt  that  chronicity  of  ulcer  depends  upon  many 
factors.  The  healing  process  of  ulcer  is  probably  prevented  in  man 
by  anomalies  in  constitution  which  are  difficult  to  install  in  animals. 
The  spastic  ischemia  results  in  the  initial  lesion.  Through  the  cor- 
rosive action  of  the  excess  of  hydrochloric  acid  the  further  develop- 
ment of  ulcer  occurs.     The  acidity  plays  undoubtedly  a  role  as  a 


92        THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

secondary  factor.  The  fact  that  in  peptic  ulcer  one  may  find  normal 
acidity,  hypo-anacidity  or  even  achylia  gastrica  does  not  prove  any- 
thing to  the  contrary.  We  know  that  the  vagotoniac  shows  in  his 
stomach  hyperchlorhydria,  but  according  to  Eppinger  and  Hess 
the  vagotoniac  might  become  a  sympathicotoniac  in  whom  low 
acidity  is  usually  found  as  a  result  of  the  change.  Aschoff's*"  expla- 
nation that  the  chronic  character  of  ulcer,  its  location,  and  its  shape, 
depend  primarily  on  the  mechanical  conditions  and  the  prolonged 
contact  with  gastric  juice  at  the  physiologic  points  of  narrowing  of 
the  stomach  and  also  upon  the  mechanical  friction  and  stress  at  the 
lesser  curvature  along  which  the  ingesta  travels  to  the  pylorus,  is 
probably  true.  He  emphasizes  that  the  chronicity  of  ulcer  does  not 
depend  on  primary  disease  of  the  blood  vessels. 

The  question  now  naturally  arises,  since  the  acute  gastric  and 
duodenal  ulcer,  the  initial  lesions  from  which  the  chronic  ulcers  may 
develop,  are  produced  experimentally  through  a  disturbance  of 
thyroid  and  adrenal,  why  are  ulcers  not  found  in  Addison's  disease, 
in  myxedema  or  in  exophthalmic  goiter?  As  to  Addison's  disease 
one  must  say  that  gastric  disturbances  do  occur  frequently.  There 
is  a  special  gastric  type  in  this  disease.  Ulcers  probably  do  not 
develop  because  Addison's  disease  is  in  the  majority  of  instances 
a  tuberculous  condition.  That  tuberculosis  has  little  affinity  for  the 
stomach  and  the  first  portion  of  the  duodenum  may  be  surmised 
by  the  fact  that  tuberculous  ulcers  of  the  stomach  or  duodenum 
are  extremely  rare  in  spite  of  the  fact  that  tuberculosis  is  a  common 
disease.  Moreover,  in  individuals  with  gastric  or  duodenal  ulcer, 
the  adrenals  may  be  found  affected,  as  seen  from  the  pathological 
findings  of  Finzi,'*"  who  showed  the  adrenals  to  be  markedly  affected 
in  five  necropsies.  I  have  seen  several  cases  of  Graves'  disease  in 
women  in  whom  symptoms  of  peptic  ulcer  were  present.  I  have 
also  recently  observed  in  two  female  patients  who  had  been  oper- 
ated for  exophthalmic  goiter,  developing  later  clear  symptoms  and 
signs  of  peptic  ulcer. 

The  increased  frequency  of  peptic  ulcer  is  a  well-known  fact  and 
this  is  certainly  due  to  the  mode  of  living — the  hurried  life,  the 
quick  lunches,  the  tremendous  business  worries,  and  generally  the 
wear  and  tear  of  life.  That  this  nervous  tension  may  lead  to  dis- 
turbances in  equilibrium  of  the  vegetative  system  is  beyond  doubt. 
The  relation  of  this  disturbance  to  the  hyper-,  hypo-  and  dys-func- 
tion  of  the  thyroid  and  adrenals,  and  reaction  of  the  secretions  of 
these  glands  in  turn  upon  the  vegetative  system  with  production  of 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        93 

constitutional  anomalies,  have  been  explained.  The  presence  of 
ulcer  in  these  cases,  the  production  of  ulcer  experimentally  under 
conditions  similar  to  that  found  in  man,  point  to  the  initial  lesion 
of  the  condition  as  due  to  disturbances  in  internal  secretions. 

Although  it  cannot  be  denied  that  the  causes  of  the  initial  lesions 
of  ulcer  are  manifold,  the  explanation  set  forth,  however,  appears 
to  be  by  far,  the  most  frequent  cause  of  ulcer. 


REFERENCES 

1.  Lichtenbelt. — Quoted  from  Westphal. 

2.  Lebert. — Beitrag  zur  Gescliichte  und  Aetiologie  des  Magengeschwiirs. 

Berlin,   Klin.   Wochcnschr.,    1876,   No.   39. 

3.  G.   V.    Bergmann. — Das   spasmogene   Ulcus   pepticum.     Miinch.    Med. 

Wochcnschr.,  1913,  H.  4. 

4.  Benecke. — Uebcr  die  hemorrhagischen   Erosionen  des   Magens    (Stig- 

mata ventriculi),  quoted  from  Westphal. 

5.  Meyer,  H.  H.,  and   Gottlieb. — Die  experimentelle   Pharmakologie. 
6,  7.  Eppinger  and  Hess. — Die  Vagotonic.     Berlin,  Hirschwald,  1910. 

8.  Kraus,  F. — Quoted   from  Westphal. 
9,  10.  Westphal  und  Katsch. — Dass  neurotische  Ulcus  duodeni.    Mitteilungen 
aus  den  Grenzgebieten  der  Aledizin  und  Chirurgie,  Bd.  26. 

11.  Diamare. — Quoted  from  Sajous. 

12.  Sajous. — The  Theory  of  Internal   Secretion.     The  Practitioner,  Feb- 

ruary, 1915. 

13.  MacCallum,  W.  G. — Quoted  from  Sajous. 

14.  Friedman,  G.  A. — A  hitherto  undescribed  form  of  polycythemia  and 

its  possible  relation  to  duodenal  ulcer,  chronic  pancreatitis  and  a 
disturbance  of  internal  secretion  (epinephrin).  Med  Rec,  October 
18,  1913- 

15.  Friedman.    G.    A. — Weitere    Erfahrungen    uber    Polyzythaemie    beim 

chronischen  uncomplizierten  Duodenalgeschwur.  Arch.  f.  Ver- 
dauungs  Krankheiten,  xix  Erganzungsheft,  1913. 

16.  Friedman,    G.   A. — The   value   of   polycythemia    for    the   diagnosis    of 

duodenal  ulcer,  based  upon  sixteen  operatively  demonstrated 
cases.     Med.   Rec,  May  16.  1914. 

17.  The  difference  in  the  morphology  of  blood  in  gastric  ulcer,  duodenal 

ulcer,    and    in   chronic   appendicitis,   based   upon    fifty   operatively 
demonstrated  cases.     Am.  Jour.  Med.   Sc,  October,  1914. 
18-20.  Bertelli,  Falta  and  Schweeger. — Ueber  die  Wechselwirkung  der  Driisen 
mit  innerer  Secretion.    Zeitschr.  f.  klin.  Med.,  Ixxi  23  and  also  Ic  i. 

21.  Imachnitzky. — Quoted  from  Biedl.     Tnnere  Seckretionen,  1913,  p.  491. 

22.  Kocher. — Quoted  from  Falta.    The  Ductless  Glandular  diseases.    Eng- 

lish translation  by  Meyers,  Blakiston,  Second  Edition,  p.  34. 

23.  Eppinger. — Quoted  from  Falta. 

24.  Kaufmann,  Jacob. — Lymphocytosis  as  a  sign  of  constitutional  derange- 

ment in  chronic  diseases  of  the  digestive  tract.  Jour.  A.  M.  A., 
1914,  Vol.  631,  p.  1104. 

25,  26.  Asher  and  Flachs. — Quoted  from   Bauer. 

27-30.  Biedl,  Dryer,  TscherboksarofT  and  Asher. — Quoted  from  Bauer. 


94       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

31.  Westphal,  Karl. — Untersuchungen  Zur  Frage  der  nervosen  Entstehung 

peptischer  ulcera.  Deutsch.  Arch.  f.  Klin.  Med.,  1914,  Bd.  114, 
p.  327. 

32.  Friedman,  G.   A. — The  experimental  production   of   lesions,   erosions 

and  acute  ulcers  in  the  duodenal  mucosa  of  dogs  by  repeated 
injections  of  epinephrin.  Jour.  Med.  Research,  1915,  Vol.  XXXII, 
No.  I. 

33.  Friedman,  G.  A. — The  influence  of  removal  of  the  adrenals  and  one- 

sided thyroidectomy  upon  the  gastric  and  duodenal  mucosa ;  the 
experimental    production    of    lesions,    erosions    and    acute    ulcer. 
Jour.  Med.  Research,  1915,  Vol.  XXXII,  No.  2. 
34.  35.  Carlson    and    Jacobsohn. — Further    studies    on    the    nature    of    para- 
thyroid tetany.    Am.  Jour.  Physiol.,  XXVIII,  133. 

36.  Finzi,  Otello. — Ueber  die  Veranderungen  der  Magenschleimhaut  bei 
Tieren  nach  Nebennierenextirpation  und  iiber  experimentelle 
erzeugte  Magengeschwiire.     Virch.  Arch.,  ccxiv,  December,   1913. 

ij.  Elliott,  T.  R. — Some  results  of  excision  of  the  adrenal  glands.  Am. 
Jour.  Physiol.,  1915,  xlix,  38. 

38.  Mann,  Frank  K.  C. — A  study  of  gastric  ulcers  following  removal  of 

the  adrenals.     Jour.  Exp.  Med.,  1916,  Vol.  23,  p.  203. 

39.  Mann,  Frank  K.  C. — A  further  study  of  the  gastric  ulcer  following 

adrenalectomy.     Jour.  Exp.  Med.,   1916,  Vol.  24. 

40.  Higier,  Heinrich. — Vegetative  oder  viscerale  Neurologic.     Ergebuisse 

d.  Neurologic  und  Psychiatric,  1912,  ii.  Heft  I. 

41.  Korte. — Quoted   from  Suzuki.     Ueber  experimentelle  Erzeugung  der 

Magengeschwiire.     Arch.  f.  klin.  Chirurgie,  Bd.  98,  1912,  p.  632. 

42.  Bauer. — Zur  Funktionsprufung  des  vegetativen  Nervensystems.    Arch. 

f.  Klin.  Med.,  1912. 

43.  Hemmeter,  John  C. — Hypertonicity  and  hypotonicity  of  the  vagus  and 

the  sympathetic  nervous  system.  N.  Y.  Med.  Jour.,  January  17, 
1914. 

44.  McCallum,  W.  G. — On  the  pathogenesis  of  chronic  gastric  ulcer.    Am. 

Med.,   1904,  viii,  452. 

45.  Huber. — Ueber  die  Erblichkeit  des  Magengeschwiirs.     Miinch.   Med. 

Wochenschr.,  1907,  January. 

46.  Aschoff. — Ueber  die  mechanischen  Momente  in  der  Pathogenese  des 

runden  Magengeschwiirs  und  ueber  seine  Beziehungen  zum  Krebs. 
Deutsche  Med.  Wochenschr.,  Vol.  xxxviii,  1912,  xxxviii,  494. 

47.  Finzi,  Ic. 


VENOUS  STASIS  AND  COLLOIDAL  DIFFUSION 

AS  ETIOLOGICAL  FACTORS  OF 

GASTRODUODENAL  ULCER 

By  FENTON  B.  TURCK 

.  New    York 

It  is  imperative  that  we  should  make  a  very  marked  distinction 
between   those  conditions   which   contribute   to    the    formation    of 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        95 

ulcers,  whether  they  be  those  of  lowered  vitality,  congenital  defects, 
or  loss  of  antibodies  that  permit  an  ulcer  to  grow.  It  is  one  thing 
to  have  predisposing  conditions,  and  it  is  quite  another  thing  to  find 
the  exact  causes  that  produce  those  conditions.  These  two  are 
widely  separated  from  one  another.  They  are  two  great  questions. 
Since  1900  my  attention  has  been  directed  to  a  study  of  the  question 
of  what  actually  does  ])roduce  ulcers,  both  in  animals  and  in  the 
human.  I  am  familiar,  as  many  of  you  know  from  my  literature  on 
the  subject,  ( i )  with  the  many  failures  to  produce  what  we  can 
recognize  and  call  true  peptic  ulcer  experimentally ;  however,  it  is 
to  be  noted  that  we  have  found  that  many  conditions  favor  the  pro- 
duction of  ulcer.  We  find,  for  instance,  that  extensive  burns  will 
sometimes  permit  ulcers  to  occur. 

It  has  now  been  found  by  surgeons  that  asepsis  has  almost  en- 
tirely prevented  those  ulcers  from  occurring  in  the  duodenum. 

Monihan,  in  his  work,  says  that  seldom  now  do  they  fail  in  pre- 
venting organisms  to  develop.  Other  surgeons,  again  have  taken  up 
the  question  of  stasis  in  the  cecum  as  a  result  of  which  micro-organ- 
isms produced  by  certain  changes,  either  by  direct  invasion  or 
through  their  toxins,  are  the  cause  of  gastric  or  duodenal  ulcer.  Dr. 
W.  H.  Barber,  writing  on  "Duodenal  Dilatability"  says,  "From  the 
results  in  this  series  of  experiments  it  appeared  that  increased 
dilatability  of  the  cephalad  duodenum  followed  complete  obstruction 
of  the  terminal  ileum ;  similar  results  have  since  been  obtained  on 
cats.  It  is  illuminative  to  see  that,  dynamically,  duodenal  tone 
appears  to  be  influenced  by  the  tone  of  the  terminal  ileum."  (2) 
Still  other  surgeons  speak  of  ulcer  originating  from  appendicitis, 
many  regarding  it  as  coming  up  by  way  of  the  venous  channels, 
by  retrograde  embolism,  and  lodging  in  the  duodenum  or  stomach, 
and  thus  producing  ulcer.  Now  they  have  empirically  carried  out 
operations,  and  have  found  that  when  they  remove  these  foci  the 
ulcers  disappeared  and  the  patients  got  well,  and  that  must  explain 
some  of  these  conditions,  remembering  always  that  empiricism  in 
medicine  merely  starts  the  inquiry  for  more  scientific  and  exact 
knowledge  through  research. 

The  work  of  Stoerck  in  emphasizing  the  part  played  by  the  status 
lymphaticus  in  ulcer  is  undoubtedly  of  value,  because  many  people 
having  ulcer  likewise  show  this  condition,  but  status  lymphaticus 
cannot  be  called  the  direct  etiological  factor  in  the  production  of 
ulcer. 

Let  us  again  revert  to  empirical  facts  gained  from  long  experience 


96       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

in  clinical  work.  It  is  known  that  uremic  ulcers  occur  and  many 
pages  have  heen  written  discussing  "Uremic  Ulcers"  hy  which 
is  meant  kidney  disease.  We  know  that  a  large  amount  of  kid- 
ney disease  is  due  to  intestinal  flora  and  we  find  that  the  intestinal 
flora  produce  a  condition  in  the  kidney  similar  to  that  found  in 
gastric  and  duodenal  ulcer,  and  there  is  no  longer  any  question 
that  we  see  in  appendicitis,  in  stasis  intestinalis,  in  conditions  of 
the  gall-bladder  and  gall-duct  conditions  exactly  similar  to  those 
found  in  gastric  and  duodenal  ulcer,  and  that  these  conditions  are 
more  or  less  directly  influenced  by  the  intestinal  flora. 

The  study  of  intestinal  flora  has  been  of  great  interest  to  me.  As 
you  may  know,  I  have  been  able  to  show,  in  my  animal  experiments, 
that  when  the  intestinal  flora  were  fed  to  animals,  ulcers  were 
produced  without  the  addition  of  trauma  or  of  any  other  injury. 
Now,  I  did  not  produce  simply  local,  small  erosions  or  small  hem- 
orrhages, but  actual  perforations.  Many  of  you  are  familiar  with 
the  many  presentations  that  I  have  made  on  ulcer  during  the  last 
sixteen  years.  (3)  An  ulcer  of  this  type  in  the  first  part  of  the 
duodenum,  with  perforation,  after  fourteen  months  of  feeding  with 
bacteria,  that  is  a  chronic  ulcer,  with  thickening  around  the  edge, 
cannot  help  but  impress  one  with  the  relation  between  the  intestinal 
flora  and  the  ulcers  that  so  consistently  followed  when  the  animals 
were  fed  as  I  have  described.  After  six  or  seven  months  feeding 
with  bacteria  during  which  time  the  animals  showed  frequent  irri- 
tation, and  finally  on  opening  them  up,  the  finding  of  deep  ulcer 
penetration  through  all  the  coats,  not  merely  an  erosion,  led  me  to 
the  conclusion  that  there  was  a  very  direct  relation  between  the  feed- 
ing experiments  and  these  ulcers.  But  this  is  empiricism  again, 
because  simply  feeding  bacteria  to  animals  and  having  ulcers  occur 
does  not  bring  us  any  nearer  a  solution  of  the  actual  mechanism  by 
which  ulcers  are  produced.  So,  it  is  necessary  to  carry  out  another 
line  of  investigation,  namely,  to  determine,  if  possible,  whether  the 
micro-organisms  act  through  the  toxins  that  are  liberated  either 
through  the  death  of  these  organisms  in  the  intestines  and  their 
breaking  down,  or  through  acting  on  the  food  in  some  unknown 
manner  producing  toxins  which  are  absorbed,  or  whether  the  micro- 
organisms themselves  afifect  some  areas  in  the  stomach  or  duodenum. 

The  evidence  that  I  have  been  able  to  deduce  from  my  experi- 
mental work  shows  that  no  inflammatory  process  takes  place ;  there 
is  no  infection  whatsoever.  When  we  inject  any  micro-organism 
into  the  veins,  we  find  them  lodged  in  the  follicles,  and  when  they 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        97 

produce  folliculitis,  sometimes  breaking  down,  the  condition  may 
look  like  an  ulcer  to  the  uninitiated ;  buf  that  is  not  true  ulcer. 
When  we  found  hemorrhagic  areas  which  we  were  able  to  produce 
by  many  means  (many  foreign  proteins  and  diflferent  varieties  of 
bacteria  injected  into  the  blood)  we  did  not  regard  these  as  any- 
thing like  ulcer  or  like  peptic  ulcer.  But  when  we  found  that  each 
coat  was  gradually  penetrated  until  finally  perforation  occurred,  we 
concluded  that  this  was  true  ulcer,  and  we  wished  to  know  the 
mechanism  occurring  in  those  experiments  that  produced  the  con- 
dition. 

It  was  found  that  when  an  animal  was  allowed  to  go  into  shock, 
or  when  any  stasis  of  the  splanchnic  area  was  introduced  as  a  factor, 
or  after  some  surgical  operation,  that  frequently  on  section,  that  the 
'intestinal  flora,  the  intestinal  bacteria,  would  pass  through  the 
mucosa,  between  the  cells,  as  though  passing  through  a  filter,  and 
that  they  would  march  onward  like  soldiers  between  the  gland  cells 
up  into  the  submucosa.  (4)  We  followed  the  destiny  of  these 
organisms  as  they  passed  along  the  submucous  tissue.  In  order  to 
have  this  exactly  and  scientifically  done,  we  decided  to  use  fetal 
animals.  This  was  done  because  the  fetal  animal  is  sterile  and  we 
can  be  certain  that  the  micro-organisms  that  we  find  migrating 
along  the  cells  are  the  ones  that  we  have  introduced. 

In  order  to  study  the  routes  by  which  the  intestinal  flora  migrated 
we  injected  a  fetal  pig  with  a  culture  of  colon  bacilli,  or  other 
intestinal  groups,  and  we  found  that  the  micro-organisms  would 
course  up  between  the  gland  cells  and  never  through  a  gland ;  that 
they  would  cross  over  the  muscularis  mucosa  into  the  submucosa, 
and  then  pass  toward  the  head,  cophalar,  until  they  reached  the 
pyloric  region.  There  we  would  find  that,  if  left  longer,  they  would 
pass  into  the  liver,  and  locate  in  different  areas  in  the  liver,  around 
the  cells,  always  passing  between  the  two  walls  of  the  common  duct, 
the  muscularis  and  the  mucosa,  and  finally  reaching  the  liver.  We 
found  that  there  was  a  direct  route  which  these  bacteria  always 
took  from  the  intestinal  tract  when  they  were  introduced  into  va- 
rious areas. 

We  then  investigated  the  routes  by  which  the  intestinal  bacteria 
migrated  in  the  adult  animal  and  found  that  under  certain  con- 
ditions they  regularly  passed  through  and  migrated  along  the  cells  in 
the  same  manner  as  they  did  in  the  fetal  animal. 

My  microphotographs  show  the  route  wdiich  the  bacteria  take  and 
also  the  variety  of  lesions  which  they  produced,  and  the  venous 


98       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

stasis  that   follows  the   reaction   which  they   incite   in   the  mucous 
membrane. 

The  peptic  ulcer  bearing  area  located  within  a  few  inches  of  the 
pylorus,  cephalic  and  caudal,  has  excited  the  most  intense  curiosity 
and  interest  since  the  earliest  discovery  of  ulcer.  The  prevailing 
conception  that  the  gastric  secretion  determines  this  location  fades 
away  under  experimental  observation.  In  experimental  ulcer  in- 
creased gastric  secretion  is  never  found.  The  rule  is  that  there  is  a 
greatly  diminished  secretion  of  hydrochloric  acid  and  the  ferments. 

In  this  connection  Lester  R.  Dragstedt,  (5)  writing  on  gastric 
juice  in  gastric  and  duodenal  ulcer,  says,  "The  digestive  activity  of 
the  gastric  juice  is  not  the  important  factor  in  the  delayed  healing 
of  acute  ulcers  of  the  stomach  and  duodenum  and  the  consequent 
formation  of  chronic  ulcers.  Ulcers  produced  by  the  local  injec- 
tion of  silver  nitrate  become  subsequently  infected  with  organisms, 
probably  from  the  alimentary  canal."  Again  Dragstdt  says,  "It  is 
well  known  that  lesions  of  the  gastric  and  duodenal  mucosa  heal 
readily  in  the  presence  of  active  gastric  juice.  Small  abrasions  of 
the  stomach  mucosa,  such  as  those  following  at  times  the  admin- 
istration of  the  stomach  tube,  are  common,  occasion  no  discomfort 
to  the  individual,  and  in  the  majority  of  cases  heal  without  further 
sequelae.  Nevertheless,  up  to  the  ])resent  time,  the  medical  and 
surgical  treatment  of  ulcer  has  been  based  essentially  on  the  theory 
that  the  gastric  juice  induces  chronicity  of  these  ulcers  by  digesting 
the  exposed  edges  of  the  mucosa. 

Rosenow  (6)  has  attempted  to  produce  acute  and  chronic  ulcers 
in  the  stomachs  of  dogs  by  the  injection  of  certain  strains  of 
streptococci,  obtained  from  the  depths  of  gastric  and  duodenal  ulcers 
in  man.  He  has  also  claimed  that  gastric  and  duodenal  ulcers  in 
man  are  usually  infected,  that  the  route  of  infection  is  by  way  of  the 
blood  stream,  and  that  the  primary  focus  may  be  in  some  distant 
part  of  the  body  (6).  Without  multiplying  references  to  the  liter- 
ature I  think  we  must  be  willing  to  admit  that  the  theory  regarding 
the  role  played  by  the  gastric  secretion  in  the  production  of  ulcer 
must  be  abandoned  and  that  we  must  search  elsewhere  for  a  tenable 
hypothesis  as  to  the  causation  of  gastric  and  duodenal  ulcer. 

If  the  acidity  of  the  gastric  juice  is  not  the  chief  inciting  factor 
in  the  production  of  ulcer  we  must  seek  elsewhere  for  an  explana- 
tion. Several  investigators  have  questioned  the  role  played  by 
bacteria.  W.  E.  and  E.  L.  Burge  (6)  from  their  experiments  con- 
clude that  the  decreased  resistance  of  a  circumscribed  area  of  the 


rilE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE        99 

Stomach  to  the  digestion  of  the  gastric  juice  is  due  to  a  decrease  in 
the  oxidative  processes  of  the  cells  of  the  area,  and  that  the  resis- 
tance of  the  unicellular  organisms  to  the  digestive  action  of  the 
proteolytic  enzymes  can  he  increased  or  decreased  by  increasing  or 
decreasing  the  intensity  of  the  oxidation  processes  of  the  organisms, 
but  he  has  failed  to  show  the  relation  of  bacterial  invasion  to  this 
oxidative  process. 

H.  L.  Celler  and  W.  Thalhimer  (7)  describe  their  own  experi- 
ments and  review  those  of  Rosenow  and  as  a  result  conclude  that  it 
must  be  assumed  that  some  cause  is  operative  in  certain  cases  of 
ulcer  preventing  the  healing  of  defects  in  the  gastric  mucosa  and  is 
inoperative  in  others.  Even  though  anhaemolytic  streptococci  are 
present  in  some  gastric  ulcers,  they  cannot  convince  themselves 
that  these  organisms  have  been  proven  as  yet  to  be  the  factor  which 
either  initiates  the  ulceration  or  prevents  healing. 

My  own  experiments  recently  have  shown  that  there  is  a  diffusion 
of  gacteria  from  the  intestinal  lumen  into  the  wall  at  dififerent 
levels  of  the  alimentary  tract.  The  laws  which  govern  the  passage 
of  the  bacteria  are  those  that  govern  the  passage  of  a  colloidal  sus- 
pension through  a  filter.  The  micro-organisms  do  not  enter  the 
blood  vessels  or  lymph  channels,  but  make  their  way  between  the 
cells  of  the  mucosa,  crossing  the  muscularis  mucosa,  passing  into 
the  interstitial  tissues  of  the  submucosa  and  meeting  antibodies  in 
this  zone,  where  the  bacteria  are  either  destroyed,  or  their  multi- 
plication prevented  by  the  antibodies  formed  in  this  area.  Bacteria 
that  are  not  destroyed  in  this  submucous  tissue  diffuse  along  the 
walls  between  the  muscular  coat  and  the  mucous  membrance,  passing 
in  the  cephalic  direction.  The  laws  that  govern  the  direction  which 
the  bacteria  take  cannot  always  be  understood.  While  passing 
upward  in  the  direction  of  the  venous  and  lymph  channels,  bacteria 
are  never  found  in  the  lymph  or  venous  streams,  but  migrate  or 
filter  between  tlie  connective  tissue  cells. 

When  the  bacteria  finally  reach  the  region  of  the  pyloric  orifice 
the  stream  is  stopped.  An  accumulation  occurs  as  a  result  of  the 
stoppage  of  this  current.  The  histological  slides  give  the  appearance 
of  a  "log  jam"  in  the  accumulated  mass  of  bacteria  in  different 
stages  of  disintegration. 

The  conditions  that  allow  the  bacteria  to  filter  in  and  along  the 
walls  of  the  intestinal  tube  are  many.  The  most  important  and 
determining  factor  is  the  alteration  in  the  venous  circulation  of  the 
intestinal  tract  (9).     Atony  of  the  intestinal  walls  associated  with 


100    THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

venous  stasis  is  one  of  the  important  causes  which  permits  filtration 
of  bacteria.  ObHteration  of  the  lumen  of  the  intestines  by  ligation 
at  different  points  is  also  effective  in  causing  filtration  of  the  bac- 
teria, but  this  filtration  depends  more  on  the  degree  of  the  dis- 
turbance of  the  circulation  than  upon  the  mere  obstruction.  (Bar- 
ber 2.)  Trauma,  catarrhal  states  of  the  mucosa  and  inflammation 
do  not  necessarily  favor  the  filtration  of  intestinal  bacteria.  If 
vessels  are  tied  off  to  produce  stagnation  of  the  blood  supply,  other 
changes  taking  place  as  leucocytosis,  marked  edema,  round-celled 
infiltration,  are  not  so  effective  in  determining  the  passage  of  the 
bacteria  into  the  walls  as  splanchnic  venous  stasis  induced  by  shock, 
anaphylaxis,  and  other  less  violent  conditions. 

The  penetration  of  the  bacteria  is  not  diffuse  but  occurs  at  selec- 
tive points  along  the  tube.  The  laws  which  govern  the  selection  of 
the  exact  point  where  bacteria  will  filter  through  are  analogous  to 
the  relation  of  a  colloidal  suspension  to  a  colloidal  substratum ;  or 
they  may  be  paralleled  by  the  adjustment  of  the  filtered  substance  to 
the  pores  of  the  filter.  The  bacteria  that  pass  into  this  submucous 
zone  often  show  immediate  bacteriolysis  on  crossing  the  mucularis 
mucosa.  Specific  antibodies  are  evidently  formed  in  the  sub- 
mucous zones  because  of  this  destruction  of  the  filtered  micro- 
organisms. Certain  intestinal  mirco-organisms,  such  as  the  colon- 
bacillus  group,  coming  in  contact  with  the  intestinal  secretions,  ac- 
quire a  relative  immunity  against  the  destructive  effect  of  the  lymph 
or  serum  in  the  submucous  tissue,  and  therefore  escape  bacterioly- 
sis. These  continue  their  journey  encephlad  to  the  region  of  the 
pyloric  orifice ;  here  meeting  much  more  powerful  antibodies  they 
are  destroyed  by  the  increased  ferments  in  this  area.  Their  destruc- 
tion in  any  accumulated  numbers  results  in  the  destruction  of  the 
tissue ;  necrosis  and  ulcer  formation  is  inaugurated. 

We  have  shown  by  titrations  of  the  blood  serum  with  suspensions 
of  cell  substance  that,  using  anaphylaxis  as  the  index,  the  cell  sub- 
stance was  200  to  1,000  times  more  powerful  in  antibodies  than  in 
the  blood  serum  of  the  same  animal.  , 

We  made  another  curious  and  remarkable  observation  which 
should  be  emphasized,  namely,  that  in  the  walls  of  the  duodenum  the 
antibodies  were  so  powerful  that  in  solution  of  one  to  one  thousand 
they  would  cause  death  when  added  to  the  intestinal  flora  injected 
into  a  rabbit,  much  more  quickly  than  the  antibodies  from  the  lower 
part  of  the  intestinal  tract.  In  some  portions  of  the  intestinal  tract, 
near  the  ileum,  the  antibodies  begin  to  lose  this  remarkable  power 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      101 

of  quickly  destroying  bacteria.  The  repetition  of  this  experiment 
many  times  over  has  led  me  to  believe  that  after  the  tying  off  of 
the  duodenum  there  are  antibodies  that  split  up  the  proteoses  and 
kill  the  animals  (because  of  their  strength  and  the  power  of  the  pro- 
teoses that  are  formed)  as  the  result  of  splitting  up  of  the  proteoses 
by  the  ferments  formed  by  the  antibodies  located  in  this  region. 

The  fact  that  the  ligation  of  the  pyloric  area  causes  death  in  the 
animal,  while  ligations  in  the  lower  tract  are  not  fatal  until  starva- 
tion supervenes,  is  undoubtedly  due  to  the  fact  of  this  greater  in- 
crease in  the  proteolytic  antibodies  in  the  duodenal  wall  as  com- 
pared with  those  of  the  lower  intestine.  Because  of  the  formation 
of  these  antibodies  in  this  zone  and  their  action  on  the  bacteria, 
the  bacteriolysis,  I  have  named  it  the  "Zona  Transformans."  Col- 
loidal suspensions  other  than  bacteria  will  also  cause  an  anaphylac- 
tic reaction  and  even  death.  For  example  Bateman  found  that  raw 
egg  white  would  cause  intense  diarrhea  in  dogs,  cats,  rabbits  and 
men,  but  that  if  the  dose  was  properly  adjusted  to  the  animal  certain 
antibodies  were  formed,  until  finally  a  tolerance  occurs. 

The  local  changes  that  are  seen  to  take  place  consist  of  an 
autolysis  of  the  tissue  cells  combined  with  a  venous  stasis  which 
shows  marked  dilatation  of  the  veins  and  contraction  of  the  arteries. 
The  appearance  of  the  tissue  indicates  what  we  understand  by  the 
generic  term,  acidosis  and  asphyxia  of  the  cells. 

Klotz  has  indicated  the  alterations  that  take  place  in  the  vessel 
walls  as  an  asphyxia  of  the  cellular  elements  (9).  The  intercellu- 
lar metabolism  is  no  longer  possible.  Wells  mentions  a  waxy  degen- 
eration due  to  an  increase  or  accumulation  of  acid  from  defective 
oxygen  supply,  which  results  in  a  fatigue  condition  of  the  muscle 
fibers.  When  this  condition  is  completed  telangiectasis  occurs,  due 
to  the  injuries  to  the  vessel  walls,  especially  of  the  venous  radicals 
with  a  corresponding  contraction  of  the  arteries.  The  deficiency 
of  oxygen  contributes  materially  to  this  permanent  loss  of  venous 
tone,  as  Hooker  has  shown  (11)  "oxygen  is  essential  to  the 
rhythmicity  in  vascular  muscle,  and  also  its  maintenance  of  tone." 

This  is  my  explanation  of  why  it  is  that  the  intestinal  flora  play 
so  important  a  part  in  the  production  of  ulcers.  And  this  is  not 
denying  the  part  played  by  other  factors,  both  in  animals  and  in 
human  beings,  or  other  conditions  that  are  favorable  to  their  pro- 
duction. But  I  still  maintain  that  when  we  have  rendered  the 
conditions  favorable,  we  have  not  yet  produced  the  exciting  cause 
of  what  we  call  ulcer.     All  these  experimental  lesions  which  I  have 


102     THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

produced  by  the  injection  of  bacteria  are  not  true  ulcer,  and  in  my 
own  study  of  all  these  different  processes  I  feel  that  these  lesions 
produced  by  the  diffusion  of  bacteria  are  more  like  ulcers  because 
of  the  slowness  with  which  they  are  produced,  and  because  they  pass 
through  the  various  stages,  producing  clear  perforations  and  finally 
death  in  the  animals,  and  this  to  my  mind  indicates  that  we  are 
working  in  the  right  direction,  remembering  that  in  all  experimental 
work  each  individual  adds  but  a  small  fraction  to  the  great  unknown. 
But  nevertheless,  I  feel  as  strongly  to-day,  even  more  strongly, 
than  when  I  first  started  this  work  sixteen  years  ago,  convinced 
of  the  truth  and  exactness  of  my  observations.  I  am  very  sure 
they  have  led  me  to  a  better  understanding  of  the  etiology  of  peptic 
ulcer  located  in  the  pyloric  and  duodenal  regions  and  has  furnished 
me  with  a  more  rational  basis  for  the  treatment  of  this  condition. 
I  feel  fully  warranted  in  making  this  statement  because  of  the  high 
average  of  good  results  that  I  have  had  since  treating  these  cases 
along  the  lines  which  these  investigations  have  suggested. 

A  review  of  the  dietetic  and  other  adjuvants  in  the  treatment  of 
ulcer  which  my  experience  has  shown  to  be  valuable  have  recently 
been  published  in  the  Medical  Record.     (June  24,  1916.) 

A  review  of  my  clinical  cases,  covering  a  period  of  fifteen  years, 
which  have  been  treated  with  autogenous  vaccines  show  a  higher 
percentage  of  permanent  good  results,  than  the  cases  treated  pre- 
viously to  that  time  without  the  vaccines.  The  ages  of  the  patients 
to  whom  this  method  of  treatment  has  been  applied  have  ranged  all 
the  way  from  infancy  to  eighty  years.  I  do  not  claim  that  the 
vaccines  have  been  the  only  factor  in  securing  unusually  good 
results,  but  that  the  vaccines  in  combination  with  the  other  methods, 
the  combined  system,  warrants  distinctly  favorable  conclusions  on 
the  basis  of  a  careful  analysis  of  the  data  presented  by  158  cases, 
in  which  complete  data  could  be  collected  and  a  much  larger  nuln- 
ber  in  which  the  data  was  more  or  less  incomplete.  While  my  con- 
clusions are  based  on  purely  empirical  results,  as  Gay  remarks 
(Jour.  A.  M.  A.,  Oct.  28,  1916,  p.  1263),  "Purely  statistical  methods 
of  investigation  must  in  more  alert  minds  yield  to  comparative 
studies."  1  have  attempted  to  place  the  experimental  facts  before 
you  and  they  seem  to  have  a  direct  relation  to  our  clinical  experience. 

REFERENCKS 

I.  Turck — Journal  of  the  A.  M.  A.,  June  Q,  1916,  pp.  1753-63. 

Turck— Transactions  of  the  American  Gastro-Enterological  Assoc,  1914. 
Turck— Journal  of  tlie  A.  M.  A.,  October  7,  1899. 
Turck — Medical  Record,  October  7,  1905. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      103 

2.  Barber — Medical    Record,    October    14,    1916.      Also    annals    of    Surgery, 

October,  1915,  pp.  433-440. 

3.  Stoerk — Deutsche  med.   Wochenschrifte,   Vol.   XXX,   No.   11. 

4.  Turck — Transactions  of  the  American  Gastro-Enterological  Assoc,   1914. 

5.  Dragstedt— Journal  of   the   A.   M.   A..   Feb.,    1917,   Vol.   LXVIII,   No.  5, 

PP-  330. 

6.  Burge— Jour.  A.  M.  A.,  1916,  LXVI,  pp.  998. 

7.  Celler  and  Thalhimer — Jour.  Experimental  Medicine,  1916,  XXIII,  pp.  791. 

8.  Ferannini— Jour.  A.  M.  A.,  Feb.  24,  pp.  668. 

9.  Klotz— Jour.  Medical  Research,  March,  1915,  Vol.  XXXII,  No.  i.  Whole 

No.   149,  p.  27. 

10.  Hooker— Journal  of  Physiology,  Vol.  XXXI,  No.  2,  Nov.  i,  1912,  p.  47. 

11.  (See  9.) 

12.  Bartholomew — Medical  Record,  August  19,  1916. 

13.  Spiethoff — Medizinsche    Klinik,    Berlin,    Nov.   26,    1916,    XI-XII,   No.   48, 

p.   1252. 

14.  Turck — Illinois  Medical  Journal,  Vol.  13,  No.  6,  pp.  631-634. 

15.  Richardson — Medical   Record,   Feb.    17,   1917,  p.  293. 

DISCUSSION  : 

Dr.  J.  C.  Hemmeter,  of  Baltimore:  A  discussion  may  be  con- 
structive or  destructive,  and  unless  we  have  some  criticism  we  shall 
drift  into  that  state  which  is  known  as  a  mutual  admiration  society. 
I  am  sorry  that  Dr.  Deaver  left.  I  invited  him  to  stay  and  hear  me 
jump  all  over  him,  but  he  said  he  was  used  to  that  sort  of  thing 
and  he  preferred  to  go.  So  I  will  not  discuss  Dr.  Deaver's  paper. 
I  heard  only  the  last  part  of  it.  I  did  not  hear  the  papers  of  Dr. 
Friedman  and  Dr.  Turck.  I  am  not  convinced  from  the  specimens 
that  Dr.  Friedman  passed  around,  or  from  his  microscopic  pro- 
jections on  the  screen  that  he  is  dealing  with  that  which  clinicians 
and  pathologists  call  a  typical  duodenal  ulcer.  Dr.  Friedman  was 
very  careful  to  speak  of  lesions  and  not  of  ulcers.  I  think  that  is  a 
very  fine  distinction.  The  rabbit  that  showed  a  duodenal  erosion 
fifteen  days  after  the  removal  of  one  adrenal,  showed  simply  what 
1  call  a  hemorrhagic  erosion,  one  of  those  predisposing  states  that 
might  perhaps  lead  to  a  duodenal  ulcer.  It  is  not  very  clear  to  me 
why  the  removal  of  one  adrenal  should  cause  this  lesion  when  the 
remaining  adrenal  is  there  to  take  up  the  function  of  its  lost  mate. 
We  know  from  physiology  and  pathology  that  the  removal  of  one 
organ  can  be  replaced  by  the  hyper- functioning  of  another.  There 
is  a  paper  on  that  .subject  in  the  November,  191 7,  number  of  the 
Experimental  Medicine  Journal,  by  Dr.  Geo.  N.  Stewart,  of  Cleve- 
land, Ohio.  It  is  not  clear  to  me  why  the  removal  of  one  adrenal 
should  cause  this  lesion  when  the  other  is  there  to  do  its  work. 


104    THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

Certainly  there  cannot  be  any  absolute  exclusion  of  function.  That 
we  find  lesions  in  the  duodenum  after  skin  burns  is  intelligible  from 
the  deductions  and  inferences  made  by  Vaughan  and  Edwin  C. 
Faust ;  the  latter  produced  a  typical  ulcer  by  the  injection  of  a  toxin 
he  called  "sepsin"  gained  from  putrecent  yeast,  and  Vaughan  by 
injections  of  arsenic.  These  substances  are  injected  under  the 
skin.  The  dead,  burnt  skin  produces  toxins,  and  if  the  bile  is 
analyzed  for  sepsin  or  arsenic,  after  the  hypodermic  injection  of  this 
metal  or  toxin,  you  find  sepsin  or  arsenic  in  the  bile.  It  is  very 
highly  probable  that  the  excretion  of  these  toxins  into  the  duodenum 
through  the  bile  can  so  poison  the  duodenal  epithelium  as  to  cause 
its  destruction ;  later  the  autolysis  goes  deeper.  What  I  call  the 
duodenal  or  gastric  ulcer  is  the  typical  histologic  picture  that  Rocki- 
tansky  first  described  so  graphically,  not  simply  the  surface  de- 
formations of  the  columnar  epithelium.  One  of  the  specimens  that 
Dr,  Friedman  showed  did  not  go  any  deeper  than  to  the  muscularis 
muscosae. 

I  also  fail  to  understand  the  application  of  the  word  "Vagotonia," 
which  means  hypertonicity  of  the  Vagus,  to  Basedow's  disease. 
The  cardinal  symptom  of  Basedow's  disease  is  fast  heart.  In 
Tachycardia  we  cannot  logically  speak  of  Vagotonia.  If  there  is 
an  excessive  tonus  of  the  Vagus  we  ought  to  expect  Bradycardia. 

Then  the  further  hypothesis  which  ascribes  a  distinct  anatomical 
picture — an  ulcer,  for  example,  in  the  duodenum — to  the  sym- 
pathicotonia, and  another  similar  lesion  only  a  half  inch  away  from 
it  in  the  pylorus  to  Vagotonia,  is  not  clear  to  me. 

I  am  very  favorably  impressed  with  the  scholarly  work  of  Turck. 
I  have  gone  very  thoroughly  into  a  critical  examination  of  his  slides 
and  they  give  evidence  of  a  perseverance  and  patience  that  is  most 
exemplary.  We  have  in  the  two  efforts  of  Friedman  and  Turck  two 
entirely  distinct  tendencies.  Friedman  attempts  to  explain  the 
production  of  duodenal  ulcer  by  a  chemical  process ;  Turck  by  a 
bacterial  process.  Through  the  production  and  destruction  of  bac- 
teria chemical  conditions  are  produced,  and  a  new  role  is  assigned 
by  Turck,  and  a  very  interesting  role,  to  the  sub-mucosa  which  he 
calls  the  Zona  transformans.  In  their  migrations  through  the  epith- 
elium the  bacteria  do  not  take  the  route  by  way  of  blood  vessels  or 
the  lymphatic  vessels.  They  permeate  between  the  cells,  and  meet 
with  their  dissolution  either  by  action  of  enzymes  -or  by  other 
processes  in  the  sub-mucosa,  which  he  regards  as  an  organ  designed 
for  that  very  purpose;  a  very  interesting  and  profound  concep- 
tion. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      105 

Dr.  J.  Kaufmann,  of  New  York  :  As  long  as  this  is  a  congress  of 
internists,  I  think  we  cannot  let  Dr.  Deaver's  remarks  pass  entirely 
unanswered.     Dr.  Deaver  made  some  very  strong  statements. 

I  shall  not  discuss  the  main  topic  of  his  paper,  the  diagnosis.     I 
will  only  point  out  that  a  diagnosis  based  exclusively  on  the  so- 
called  characteristic  subjective  symptoms  is  entirely  unreliable.     I 
have    seen    too   many   cases    where   a    positive    diagnosis    on    such 
a  basis  was   made   and   where   at  operation   no   ulcer   was   found. 
Dr.  Deaver  actually  dared  internists  to  treat  duodenal  ulcer,  threat- 
ening that  we  have  to  take  all  the  responsibility  for  whatever  hap- 
pens to  any  one  having  duodenal  ulcer.     Gentlemen,  I  am  willing 
to  take  that  responsibility.     I  feel  that  when  I  advise  a  patient  to 
undergo  an  operation  the  responsibility  I  take  upon  me  is  often- 
times very  much  more  serious.     The  surgeon  would  be  entitled  to 
make  the  statement  that  Dr.  Deaver  made  if  he  could  show  us  that 
surgical  treatment  of  duodenal  ulcer  accomplishes  a  permanent  cure  ; 
but  I  am  sorry  to  say  that  that  is  not  so.     I  may  mention  here  as 
a  historical  fact  that  exactly  thirty  years  ago,  in  the  winter  of  1886, 
the  tirst  patient  ever  operated  upon  for  gastric  ulcer  was  a  patient 
of  mine,  when  I  was  an  assistant  at  Kussmaul's  clinic.     Since  then 
I  have  had  opportunities  to  follow  cases  of  gastric  and  duodenal 
ulcer  operated  upon  on  the  other  side  of  the  water  and  here,  and 
operated  upon  by  the  most  illustrious  surgeons,  and  have  seen  the 
results.     I  can  only  judge  by  the  results  obtained  in  my  own  cases, 
and   I  must  confess  that  in  a  high  percentage  of   cases  the  final 
results  were  poor.     I  used  to  be  a  very  enthusiastic  advocate  of 
surgical  treatment,  but  the  frequent  observation  of  poor  immediate 
and  poor  final  results  have  made  me  more  and  more  conservative. 
Now,  I  think  twice  before  I  have  a  patient  operated  upon.     With- 
out discussing  the  indications  for  surgical  treatment,  I  only  wish 
to  say  that,  generally  speaking,  the  indication   for  surgical  treat- 
ment comes  up  when  medical  methods  fail,  when  the  ulcer  proves 
intractable.     We  cannot  admit  that  operation  per  se  is  the  para- 
mount treatment  of  ulcer  cases,  because  no  operative  procedure, 
not  even  the  resection  of  the  ulcer  itself,  removes  the  pathological 
condition  which  caused  its  formation  and  may  give  rise  to  new  dis- 
turbances.    I  think  Dr.  Deaver,  like  most  surgeons,  is  under  the 
misapprehension  that  the  anatomical  changes   which   they  find  in 
opening  up  a  patient  are  the  "whole  show,"  to  use  a  slang  expres- 
sion.    It  is  not  so  by  any  means.     The  anatomical  changes  which 
are  found  in  the  stomach  or  duodenum  are  effects  of  the  pathological 


106    THE  AMERICAS  CONGRESS  OX  EXTERNAL  MEDICINE 

process  and  not  the  cause.  They  may  become  contributory  factors, 
but  are  never  the  original  cause.  Dr.  Friedman  in  his  very  inter- 
esting paper  struck  upon  the  right  road.  I  think  we  shall  come 
to  an  understanding  of  the  pathogenesis  of  peptic  ulcer  if  we  study 
more  physiological  pathology  instead  of  relying  entirely  upon 
anatomical  pathology.  Dr.  Friedman's  suggestion  is  a  very  inter- 
esting one.  At  present  I  am  not  in  a  position  to  judge  its  value,  but 
I  shall  certainly  take  it  up  and  see  whether  there  is  any  such  possi- 
bility of  differential  diagnosis  between  duodenal  and  gastric  ulcer 
on  the  basis  of  different  disturbances  in  the  vegetative  nervous  sys- 
tem possibly  brought  on  by  disorders  of  the  internal  secretions. 

I  would  like  to  refer  to  one  more  statement  which  Dr.  Deaver 
made.  He  said,  and  the  observation  is  correct,  that  most  of  those 
patients  have  their  attacks  of  annoying  subjective  symptoms  either 
in  the  fall  or  iii  the  spring,  at  all  events,  periodically,  and  he  cor- 
rectly emphasized  that  they  are  perfectly  free  of  symptoms  during 
the  interval.  Now,  gentlemen,  if  the  anatomical  changes  are  the 
cause  of  the  symptoms,  why  is  it  that  these  patients  are  free  from 
symptoms  for  long  periods,  a  whole  year  and  more,  while  the  ana- 
tomical changes,  the  defect  caused  by  the  ulceration,  the  adhesions, 
etc.,  remain  practically  unchanged?  There  must  be  something  else 
which  provokes  the  symptoms,  and  think  that  the  disorders  of  the 
vegetative  nervous  system,  whatever  may  bring  them  about,  are 
the  real  cause  of  the  periodical  upset  as  well  as  of  the  original 
development  of  the  ulcer. 

Now,  regarding  Dr.  Hemmeter's  remark,  I  do  not  think  that  we 
need  to  make  such  a  sharp  distinction  between  the  physical  and 
chemical  aspect  as  expressed  in  Dr.  Friedman's  paper,  and  the  bac- 
teriological view  followed  by  Dr.  Turck  in  his  most  interesting  in- 
vestigations. We  need  them  both.  It  is  very  well  possible  that 
physical  and  chemical  disorders  brought  on  by  disturbances  in  the 
vegetative  nervous  system,  create  that  condition  of  lowered  vitality 
in  the  gastro-intestinal  tract  which  then  gives  the  bacteria  an 
entrance  into  the  system,  and  that  then  with  the  persistence  or 
rather  the  periodicity  of  the  disorders  of  the  vegetative  nervous 
system,  we  get  what  finally  is  ulcer.  I  think  this  is  a  very  impor- 
tant point,  and  that  it  also  applies  to  Dr.  Hemmeter's  criticism  of 
Dr.  Friedman's  findings.  We  are  not  able  to  reproduce  the  ulcer 
as  we  find  it  in  the  human  being,  because  we  cannot  reproduce  the 
periodical  upset  of  the  vegetative  nervous  system  caused  by  dis- 
orders of  the  internal  secretions. 


THE  AMERICAS  CONGRESS  OX  INTERNAL  MEDICINE      107 

Dk.  J.  R.  Vekbkvcke,  of  Washington,  D.  C.  :  It  seems  to  me 
unwise  to  accept  the  surgeon's  criteria  for  diagnosis.  His  viewpoint 
and  methods  are  altogether  different  from  ours.  In  the  first  place, 
he  sees  ulcers  whicli  are  of  only  one  class — they  are  chronic  ulcers. 
We  also  unfortunately  see  chronic  ulcers,  but  we  also  see  many 
others.  The  internist  is  not  to  blame  because  the  surgeon  sees  the 
ulcers  after  many  years  of  duration,  as  Dr.  Deaver  says  himself, 
but  partly  the  patient  and  partly  the  general  practitioner.  The 
surgeon  attempts  to  make  a  diagnosis  of  cancer  of  the  stomach 
before  typical  symptoms  appear,  and  yet,  on  the  other  hand,  in  the 
diagnosis  of  ulcer  of  the  duodenum  he  bases  his  diagnosis  on  a 
typical  case,  or  what  he  calls  a  typical  case.  Now  the  surgeon's 
diagnostic  viewpoint  is  mainly  from  the  symptomatic  side.  The 
internist  believes  in  using  the  symptoms,  the  physical  examination, 
and  every  clinical  sign  which  is  at  his  disposal,  and  by  so  doing,  I 
believe  that  the  internist,  when  he  is  able  to  give  this  complete 
examination,  is  able  to  diagnose  over  ninety  per  cent,  of  the  duo- 
denal ulcers,  and  that  he  can  do  it  before  they  get  to  their  chronic 
stage.  Duodenal  ulcer  represents  the  only  dyspeptic  condition  which 
we  can  with  any  certainty  in  some  cases  diagnose  from  symptoms 
alone.  Even  then  it  is  not  advisable  in  those  typical  cases  to  make 
a  prognosis  or  operate  or  treat  medically  without  a  more  complete 
examination,  if  possible,  because  mistakes  can  occur  both  ways. 
There  are  many  typical  cases  which  do  not  give  the  typical  peri- 
odicity and  so  forth.  ( )n  the  other  hand,  I  have  seen  other  cases 
which  before  operation  gave  clinical  pictures  of  typical  duodenal 
ulcer  and  which  w^ere  due  to  adhesions  from  the  gall  bladder  to 
the  duodenum  and  the  contraction  of  the  duodenum  by  means  of 
these  adhesions,  giving  hunger  pain.  I  have  also  seen  similar 
symptoms  occur  from  contraction  by  an  adherent  omentum,  an 
omentum  adherent  in  the  pelvis  in  two  or  three  cases.  So  that  in 
direct  proportion  to  the  completeness  of  our  examination  will  our 
results  vary.  I  believe  that  the  internist  is  able  to  make  a  better 
diagnosis  before  operation  than  the  surgeon  is  at  the  time  of  oper- 
ation. This  brings  us  to  the  question  of  unfound  ulcers,  which  I 
cannot  go  into  at  this  time,  but  of  which  I  could  cite  case  after 
case.  Nor  can  I  take  the  various  means  in  detail  by  which  the 
internist  does  make  his  diagnosis  of  duodenal  ulcer.  Just  a  w^ord 
about  prognosis.  When  the  surgeon  can  show  us  a  larger  propor- 
tion of  cases  cured  after  fifteen  years  than  joslyn  shows  of  forty 
p.er  cent,  after  surgery  and  thirty-eight  per  cent,  after  medicine,  we 


108     THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

will  have  our  cases  operated  on  more  often.  But  certainly  these 
statistics  showing  only  forty  per  cent,  cured  after  fifteen  years 
under  surgery,  and  thirty-eight  after  medicine,  shows  that  there  is 
something  decidedly  unsolved  by  our  present  treatment,  and  that 
there  is  a  lot  for  us  to  live  for  yet  in  the  treatment  of  ulcer. 

Another  thing,  the  surgeon  in  his  estimation  as  to  whether  the 
case  is  cured  or  not  goes,  as  in  his  diagnosis,  usually  on  symptoms. 
He  writes  to  the  patient,  ''Are  you  free  from  symptoms?"  The 
patient  may  be  free  from  symptoms,  but  oftentimes  for  months  and 
years  afterwards,  if  examination  is  made,  the  stools  will  be  loaded 
with  occult  blood.  He  still  has  a  little  keg  of  gunpowder,  just  the 
same  as  he  did  before  he  was  operated  on. 

Just  one  word  more  in  closing.  I  would  like  to  call  to  the  atten- 
tion of  Dr.  Friedman,  when  he  speaks  of  the  inherited  tendency  to 
ulcer,  that  I  have  published  a  report  of  two  cases  of  what  I  call 
ulcer  families  with  hereditary  predisposition  to  ulcers  in  one  family, 
in  which  the  mother  and  three  children  were  proven  to  have  ulcers ; 
and  in  the  second,  the  mother  and  two  children;  and  I  know  one 
other  ulcer  family  which  I  have  not  reported. 

Dr.  J.  W.  Weinstein,  of  New  York:  I  am  purely  a  medical 
man  and  not  a  surgeon,  but  I  must  say  that  when  it  comes  to  the 
diagnosis  of  a  duodenal  ulcer  I  side  with  Dr.  Deaver  and  with  all 
the  other  prominent  surgeons  who  hold  exactly  the  same  view  that 
Dr.  Deaver  holds.  Now  we  all  must  admit  that  the  diagnosis  of 
duodenal  ulcer  has  undergone  very  radical  changes.  We  all  must 
admit  that  a  few  years  ago  medical  men  did  not  know  how  to  diag- 
nose duodenal  ulcer.  It  was  considered  a  feat.  It  was  considered 
an  effort  worthy  perhaps  of  a  great  medical  man.  In  fact,  we  did 
not  know  at  all  the  great  frequency  of  duodenal  ulcer.  To-day,  this 
is  a  diagnosis  that  is  in  the  hands  of  every  tyro.  Now,  Dr.  Deaver 
told  us  how  to  do  that.  I  think  perhaps  that  medical  men  look  for 
something  difficult,  for  something  complicated,  and  when  something 
plain  is  handed  over  to  them  it  seems  they  do  not  care  to  take  it. 
Now,  when  a  patient  complains  of  pain,  of  oppression  in  his  chest 
or  in  his  stomach,  coming  on  three,  four  or  five  hours  after  a  meal ; 
if  he  has  got  with  those  pains  perhaps  heartburn,  belching,  sour 
eructations;  if  those  symptoms  are  relieved  by  ingestion  of  food; 
if  they  are  relieved  by  vomiting;  that  patient  has  a  duodenal  ulcer. 
Now,  Dr.  Deaver  has  cited  hundreds  of  cases.  Dr.  Munyon  has 
cited  hundreds  of  cases  that  he  has  operated  on.     Dr.  Mayo  and  all 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      109 

of  the  prominent  surgeons  in  the  country  testify  to  that,  and  I 
really  see  no  reason  why  we  should  not  give  heed  to  it. 

The  periodicity  is  also  a  very  important  point.  When  we  find 
a  patient  tell  us  that  he  gets  dyspeptic  perhaj)s  for  a  few  weeks 
once  a  year,  perhaps  two  or  three  weeks  a  year,  -a  diagnosis  of 
duodenal  ulcer  is  probably  right. 

While  I  side  with  Dr.  Deaver  on  the  diagnosis  of  duodenal  ulcer, 
I  differ  with  him  and  hold  with  my  colleagues  on  the  treatment ; 
because  if  any  one  would  ask  me  what  is  the  disease  I  can  treat 
better  than  anything  else  I  would  say  unhesitatingly  that  I  can  treat 
duodenal  ulcer  with  better  success  than  any  other  intestinal  disease. 
I  used  the  method  a  little  over  five  years  ago ;  I  read  a  paper  on 
it,  and  it  has  stood  the  test  of  time. 

Dr.  W.  J.  Mallory,  of  Washington,  D.  C.  :  On  the  question  of 
the  diagnosis  of  ulcer  I  think  that  what  surgeons  neglect  to  remem- 
ber is  that  before  cases  come  to  them  they  have  come  out  of  the 
doubtful  class;  and  that  the  surgeon  sees  more  of  the  typical  cases 
that  are  easier  to  diagnose,  and  also  the  class  of  cases  which  need 
surgical  treatment.  Until  we  find  an  actual  exciting  cause  for 
ulcer,  and  it  seems  that  Dr.  Turck's  paper  is  certainly  on  a  very 
suggestive  line  of  investigation,  we  are  face  to  face  with  the  prob- 
lem as  to  what  we  shall  do  with  our  patients  who  present  the  well- 
known  symptoms  of  gastric  or  duodenal  ulcer — what  the  treatment 
shall  be.  My  opinion  is,  in  the  light  of  what  we  have  heard,  that 
our  treatment  for  those  conditions  is  medical,  unless  complica- 
tions have  developed,  and  then  it  is,  that  the  lesions  are  so  marked, 
so  definite,  that  they  set  up  a  new  train  of  symptoms  that  are  so 
disturbing  that  they  must  be  rellieved  by  surgical  means. 

One  last  point :  When  the  diagnosis  is  correct  and  the  oper- 
ation has  been  performed,  and  the  patient  has  been  treated  in  the 
hospital,  and  dismissed  cured,  he  still  has,  as  Dr.  Verbrycke  says, 
his  keg  of  powder  with  him.  He  still  has  all  of  those  predisposing 
causes  that  produced  his  gastric  ulcer  and  some  of  his  physical 
symptoms  and  disturbances,  and  he  is  still  to  be  guided  in  a  medical 
way  or  he  will  soon  be  a  sick  man  again. 

Dr.  W.  H.  Stewart,  of  New  York  :  I  simply  want  to  go  on  record 
in  favor  of  the  Roentgen  diagnosis  of  duodenal  ulcer.  Dr.  Deaver's 
statistics  of  two  hundred  cases  with  one  hundred  and  ninety-two 
typical  and  only  eight  atypical,  does  not  agree  with  my  observations 


no    THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

in  this  locality.  Those  that  I  come  in  contact  with  show  at  least 
fifty  per  cent,  atypical.  In  mose  of  the  typical  cases  I  should  place 
the  clinical  history  as  No.  i  and  the  Roentgen  findings  as  No.  2 ; 
but  in  the  atypical  cases  I  believe  the  Roentgen  examination  is  the 
most  accurate  means  of  diagnosis,  and  I  should  place  it  as  No.  i. 
We  have  absolute  objective  signs  of  duodenal  ulcer  in  the  majority 
of  cases.  I  do  not  mean  to  say  in  one  hundred  per  cent,  by  any 
means,  but  I  believe  my  statistics  will  show  something  like  ninety 
per  cent,  of  correct  diagnoses  in  all  cases.  I  am  sure  that  in  many 
we  have  vague  symptoms  from  obscure  lesions  in  the  right  upper 
quadrant  which  are  not  so  easy  to  "clear  up"  as  Dr.  Deaver  would 
lead  us  to  believe. 

Dr.  J.  C.  Hemmeter,  of  Baltimore:  I  would  like  to  ask  the  gen- 
tleman whether  he  does  ascribe  more  importance  to  the  exact  clinical 
history  than  to  the  radiograph? 

Dr.  W.  H.  Stewart,  of  New  York  :  I  said  in  typical  cases,  Doc- 
tor. I  believe  I  would  place  the  clinical  history  as  No.  i  and  the 
Roentgen  findings  as  No.  2 ;  but  in  the  atypical  cases  I  would  place 
the  Roentgen  findings  as  No.  i. 

Dr.  M.  Cross,  of  New  York:  I  would  like  to  ask  Dr.  Friedman 
if  he  was  looking  for  these  lesions  in  other  parts  of  the  body,  in  the 
intestines,  heart,  etc.,  and  whether  he   found  them. 

Dr.  G.  Lenox  Curtis,  of  New  York  :  In  1892,  I  found  that 
specimens  of  fresh  syphlitic  sores  and  those  of  early  cancer  growth, 
appeared  practically  the  same  under  the  microscopic,  and  later,  that 
the  blood  of  all  cancer  patients  contained  crypta-syphlitica. 

In  1906  a  paper  by  me  claiming  syphilis  to  be  the  etiology  of 
cancer,  appeared  in  the  New  York  Medical  Record. 

I  place  all  my  cases  under  anti-syphlitic  treatment,  and  all  recover. 
But  where  it  is  possible  to  inject  into  the  growth  an  astringent 
which  ligates  the  blood  vessels  entering  it,  I  do  so,  with  the  result 
that  the  growth  is  exfoliated,  and  the  wound  fills  in  with  healthy 
tissue.  I  have  practiced  chemical  surgery  in  this  class  of  cases  for 
17  years  and  believe  it  to  be  the  best  known  method. 

Dr.  G.  a.  Friedman,  of  New  York  :  I  wish  first  to  reply  to  Dr. 
•Hemmeter.     At  the  start  I  want  to  make  it  clear  that  I  did  not 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      111 

intend  to  demonstrate  to  yovi  typical  ulcers  or  cinonic  ulcers  which 
you  see  at  operation.  This  was  not  the  purpose  of  my  paper,  nor  of 
my  work.  I  am  dealing  practically  with  the  initial  lesion,  the  ex- 
planation of  which  is  by  far  more  important  than  the  factors  which 
help  to  develop  the  ulcers  from  the  initial  lesions.  Suppose  some  in- 
vestigators, as  I  have  recently  seen,  succeeded  in  producing  chronic 
gastric  ulcers  by  injections  of  nitrate  of  silver.  It  is  self-evident 
that  nitrate  of  silver  cannot  be  the  cause  of  the  ulcer  in  man.  In 
my  paper  I  simply  wanted  to  state,  and  to  emphasize  the  possibility 
of  the  initial  lesion  of  ulcer  as  dependent  on  a  disturbance  of  in- 
ternal secretions.  I  have  therefore  dealt  with  the  vegetative  nervous 
system.  I  have  shown  its  relation  to  the  thyroid  and  adrenals  and 
to  anomalous  constitutions. 

I  have  brought  out  the  effects  of  the  disturbances  in  the  secretion 
of  these  ductless  glands  on  the  nervous  system  itself  producing 
the  various  clinical  types  of  patients  with  ulcer.  I  have  explained 
in  detail  how  the  initial  lesion,  ischemia  of  the  gastric  or  duodenal 
mucosa,  may  develop  from  a  spasm  of  the  smallest  arterioles  or 
from  spasm  of  the  muscularis  by  an  irritable  condition  of  the  vege- 
tative nerves.  Then  with  the  other  contributive  factors  a  typical 
chronic  ulcer  may  result.  I  have  stated  in  my  paper  that  after 
extirpation  of  both  adrenals  the  lesions  are  much  more  pronounced 
than  after  extirpation  of  one  adrenal,  but  nevertheless  you  find 
lesions  after  extirpation  of  one  to  a  somewhat  less  marked  degree. 

In  regard  to  Dr.  Hemmeter's  remarks  that  if  one  adrenal  is 
extirpated  the  other  hypertrophies,  I  must  say  that  this  is  frequently 
not  the  case,  for  in  many  cases  after  one-sided  adrenalectomy,  the 
unextirpated  adrenal  is  not  found  larger.  However,  hypertrophy 
of  the  remaining  adrenal  does  occur  and  especially  so  in  guinea-pigs. 
There  are  usually  no  accessory  adrenals. 

Secondly,  I  would  like  to  clear  up  the  question  of  the  so-called 
vagotonic  type  of  Graves'  disease.  This  is  not  my  work,  but  the 
work  of  Eppinger  and  Hess,  who  distinguish  between  the  sym- 
pathicotonic and  vagotonic  form.  It  is  said  by  these  authors  that 
in  the  latter  type  there  is  a  slight  degree  of  tachycardia  and  other 
signs  pointing  to  an  irritation  of  vagus  rather  than  of  the  sym- 
pathicus. 

As  to  the  last  remark  of  Dr.  Hemmeter  why  individuals  afflicted 
with  duodenal  ulcer  should  present  more  sympathicotonic  symptoms, 
and  individuals  afflicted  with  gastric  ulcer  more  vagotonic  symptoms, 
I  cannot  give  a  definite  answer.    But  it  seems  to  me  that  the  reason 


112    THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

may  be  that  the  sympathetic  nerve  element  is  more  pronounced  in 
the  duodenum  and  the  vagus  element  in  the  stomach.  The  soil  of 
the  duodenum  may  also  differ  from  the  soil  of  the  stomach.  It  is 
rather  peculiar  than  cancer  is  so  frequent  in  the  stomach  and  so 
rare  beyond  the  pyloric  vein  in  the  first  portion  of  the  duodenum. 

Dr.  Kaufmann's  question  is  practically  answered  by  my  remarks 
to  Dr.  Hemmeter.  As  to  Dr.  Gross's  question,  in  regard  to  whether 
lesions  were  found  in  other  parts  of  the  body,  I  have  stated  in 
my  previous  papers  that  lesions  were  occasionally  found  in  other 
abdominal  organs,  but  were  not  nearly  as  constant  nor  as  pro- 
nounced as  in  the  stomach  or  duodenum.  Occasionally  lesions  in  the 
appendix  were  found,  and  I  myself  have  made  notes  of  such  cases. 
This  would  in  addition  show  the  relationship  possibly  existing  be- 
tween a  disturbance  of  internal  secretions  and  the  appendix.  And 
as  a  matter  of  fact,  we  really  do  not  know  as  yet  the  cause  of 
appendicitis. 

Dr.  F.  B.  Turck,  of  New  York  :  I  regret  that  the  discussion  did 
not  take  up  more  definitely  the  ideas  of  etiology,  of  pathology  itself, 
from  a  phyiological  and  pathological  standpoint.  We  would  expect 
that  from  a  society  of  internists,  who  ought  to  be  most  interested  in 
it  above  all  things ;  for  remember,  gentlemen,  in  this  great  question 
is  involved  not  alone  the  problem  of  duodenal  ulcer;  there  is  in- 
volved a  higher  and  a  greater  problem  than  this :  Why  we  don't  de- 
stroy ourselves ;  and  I  have  attempted  in  my  investigations  to  ask  the 
question,  not  why  we  do  not  destroy  ourselves,  but  why  are  we  not 
all  destroyed?  Why  does  an  ulcer  form,  is  one  question,  but  why 
we  are  not  destroyed  is  another  great  question.  This  autolysis  that 
is  going  on  is  a  normal  process.  Why  does  it  become  pathological 
in  a  localized  area?  We  must  revert  back  again  now  and  then  to 
the  empiric  facts  that  are  gained  from  long  experience  in  clinical 
work.  It  is  known  now  that  uremic  ulcers  occur;  many  pages  are 
given  by  Moynihan  to  the  presence  of  uremic  ulcers,  meaning  kid- 
ney disease.  We  know  that  a  large  amount  of  our  kidney  disease  is 
due  to  our  intestinal  flora,  and  we  find  that  the  intestinal  flora  pro- 
duces the  same  condition  in  the  kidney  that  we  sometimes  find 
in  ulcer  conditions,  so  that  in  appendicitis,  in  stasis  intestinalis,  in 
conditions  of  the  gall-bladder  and  gall  duct  we  see  similar  processes 
and  lesions. 

The  effect  of  the  data  given  by  Dr.  Friedman  is  very  illuminating 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      113 

and  very  valuable,  and  we  must  consider  that  there  are  certain 
conditions  which  permit  the  condition  he  describes  to  exist.  I  have 
chosen  for  my  part,  this  attempt  to  enlighten  us  a  little  more  upon 
the  relation  between  the  intestinal  flora,  and  I  am  more  convinced 
than  ever,  as  I  said  before,  that  we  have  here  an  opportunity  for 
further  and  wider  investigation.  Much  of  this  will  depend  upon 
some  of  you  who  are  interested  sufficiently  in  the  great  problem ; 
for  internal  medicine  hangs  on  many  of  these  questions.  We  cannot 
go  into  such  investigations,  but  there  is  no  barrier  against  it  if  you 
want  to  undertake  it. 


114    THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE. 


CONSTITUTION 

ARTICLE  I 

This  Organization  shall  be  known  as  The  American  Congress  on 
Internal  Medicine. 

ARTICLE    II 

The  objects  of  the  Congress  shall  be:  To  promote  the  advance- 
ment of  the  science  and  practice  of  medicine,  to  further  the  study 
of  biological  medicine  among  its  members,  to  elevate  the  standard  of 
preliminary  education  of  physicians  and  the  standing  of  medical 
education,  and  secure  enactment  of  just  medical  laws  by  the  State 
and  Federal  Governments  and  of  a  Federal  Law  providing  for  a 
national  medical  license,  to  obtain  the  establishment  of  a  National 
Board  of  Health,  to  promote  friendly  intercourse  among  physicians, 
to  enlighten  and  direct  public  opinion  in  regard  to  the  great  prob- 
lems of  health  and  medicine,  and  to  unite  those  working  in  the 
domain  of  internal  medicine,  to  secure  recognition  for  the  term 
internist  as  the  proper  designation  for  such  workers  and  to  obtain 
proper  scientific  and  material  recognition  of  their  work. 

ARTICLE    III 

The  Congress  shall  meet  annually  at  such  time  and  place  as  the 
Council  may  determine.  Twenty-five  members  shall  constitute  a 
quorum. 

ARTICLE    IV 

Section  i.  The  officers  of  the  Congress  shall  consist  of  a  Presi- 
dent, a  Vice-President,  a  Secretary-General,  a  Treasurer,  and  twen- 
ty-five Councilors,  who  with  the  officers  shall  constitute  the  Council, 
all  to  be  elected  from  the  active  membership  by  ballot  at  an  annual 
meeting,  a  majority  of  whom  shall  reside  in  the  City  of  New  York 
or  its  vicinity,  excepting  that  the  Secretary-General  shall  be  elected 
for  a  term  of  ten  years. 

Sec.  2.  The  Council  may  be  convened  at  any  time  by  the  Presi- 
dent at  the  request  of  any  five  of  its  members.  Its  decisions  shall 
be  equivalent  to  acts  of  the  Congress,  and  shall  be  reported  to  it  at 
its  next  regular  meeting.  The  Council  shall  constitute  the  nom- 
inating committee  of  the  Congress. 

Sec.  3.  A  vacancy  occurring  in  any  office  may  be  filled  by  the 
Council. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      115 

ARTICI.E  V 

Section  i.  Any  qualified  physician  engaged  in  the  general  or 
special  practice  of  internal  medicine  or  in  laboratory  research  per- 
taining to  it,  may  be  proposed  for  fellowship. 

Sec.  2.  Applications  for  fellowship  in  the  Congress  should  be 
made  in  writing  to  the  Council.  Five  negative  ballots  shall  reject 
an  applicant. 

Sec.  3.  Applications  for  fellowship  shall  be  accompanied  by  the 
annual  dues  of  five  dollars. 

Sec.  4.  Resignation  of  fellows  shall  not  be  accepted  until  all 
dues  have  been  paid. 

article  VI 

All  proposed  changes  in  the  constitution  must  be  offered  in  writ- 
ing at  a  regular  meeting  of  the  Congress.  They  are  to  be  consid- 
ered only  at  the  next  annual  meeting  when  a  two-thirds  vote  of  the 
members  present  shall  be  necessary  for  their  adoption. 


BY-LAWS 


article  I 


The  President  shall  preside  at  the  annual  meeting  of  the  Con- 
gress and  deliver  an  address,  and  shall  be  the  chairman  of  the 
Council.  In  the  absence  of  the  President,  the  Vice-President  shall 
preside. 

ARTICLE    II 

The  Secretary-General  shall  keep  a  record  of  the  transactions  of 
the  Congress,  and  the  Council,  and  committees,  conduct  all  corre- 
spondence of  the  Congress,  and  mail  to  each  fellow  a  program  of 
the  meeting  at  least  two  weeks  in  advance  of  the  date  thereof. 
The  records,  publications  and  seal  of  the  Congress  shall  be  in  his 
custody. 

ARTICLE    III 

The  Treasurer  shall  collect  all  moneys  due  the  Congress,  disburse 
the  same  as  directed  by  the  Council,  keep  a  proper  account  of  all  his 
transactions,  and  render  an  annual  statement  to  the  Congress.     He 


116    THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

shall  have  charge  of  all  property  belonging  to  the  Congress  not 
otherwise  provided  for.  He  shall  give  bonds  for  the  faithful  per- 
formance of  his  duty,  in  such  sum  as  shall  be  determined  by  the 
Council. 

ARTICLE  IV 

The  Council  shall  constitute  a  standing  committee  to  consider  all 
matters  of  interest  to  the  Congress.  It  shall  appoint  all  commit- 
tee and  conduct  all  business  affairs  of  the  Congress.  It  may,  in  its 
discretion,  organize  special  scientific  and  local  sections  of  the 
Congress. 

Five  members  of  the  Council  shall  be  elected  annually  by  the  Con- 
gress, each  to  serve  for  a  term  of  five  years. 

ARTICLE   V 

Charges  against  any  fellow  must  be  made  in  writing.  They 
shall  be  referred  to  the  Council  for  investigation  and  action. 

ARTICLE    VI 

The  annual  dues  shall  be  five  dollars,  payable  before  the  annual 
meeting. 

ARTICLE    VII 

The  order  of  business  shall  be  as  follows : 

(i)   Reading  of  the  minutes  of  preceding  meeting. 

(2)  Reports  of  officers,  of  the  Council  and  committees. 

(3)  Presentation  of  communications. 

(4)  Miscellaneous  business. 

(5)  Election  of  officers  for  the  ensuing  year. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      117 


FELLOWS    OF    THE    AMERICAN    CONGRESS    ON 
INTERNAL  MEDICINE,  1916-1917 


Aaron,    Charles    ().,    Detroit,    Mich. 
Acuff,   S.   D.,    Knoxvillc,   Tcnii. 
Ager,  Louis  C,   Brookl}!!,   N.   V. 
Alsop,    Thos.,    Atlantic    City,    N.    J. 
Amster,   J.    Lewis,    New    York    City. 
Anders,  James  M.,  Philadelphia,  Pa. 
Arneill,  James  Rae,   Denver,  Colo. 
Aten,   William    H.,    Brooklyn,   N.    Y. 
Atkin,  S.  J.,  Brooklyn,  N.  Y. 
Attshul,   H.,   Hartford,   Conn. 

Baar,    Gustav,    Portland.    Ore. 
Babcock,    Robert    H.,    Chicago,    111. 
Bacon,  Theo.  T.,  Springfield,  Mass. 
Baketel,    H.    S.,    New    York    City. 
Bangs,  Charles  H.,  Boston,  Mass. 
Barach,  Jos.   H.,    Pittsburgh,    Pa. 
Barnes,   James,    Chicago,    111. 
Barnes,  Noble  P.,  Washington,  D.  C. 
Bartley,   E.   H.,    Brooklyn,    N.    Y. 
Bate,  R.  Alex.,  Louisville,  Ky. 
Bathurst,  Wm.  R.,  Little  Rock,  Ark. 
Beck,  Harvey  G.,  Baltimore,  Md. 
Bcling,  C.  C,  Newark.  N.  J. 
Bell,  John  M.,  St.  Joseph,  Mo. 
Benedict,   A.    L.,    Buffalo,    N.    Y. 
Berg,   G.    F..    Pittsburgh,    Pa. 
Berger,  Samuel  S.,  Cleveland,  O. 
Bettman,    Henry   W.,    Cincinnati,    O. 
Betts,    Lester,    Schenectady,    N.    Y. 
Beyer,  Louis  J.,  Buffalo.  N.  Y. 
Biddle,    Andrew    P.,    Detroit,    Mich. 
Bieber,  Joseph,  New  York  City. 
Billings,    Fredk.    T.,    Pittsburgh,    Pa. 
Bishop,   Ernest   S.,    New    York   City. 
Bishop,   James,    New    York   City. 
Bishop,  L.  F.,  New  York  City,  N.  Y. 
Bloch,    Leon,    Chicago,    111. 
Blackwood,    A.    L.,    Chicago    111. 
Bohan    P.   T.,   Kansas   City,   Mo. 
Bonney,   Sherman   G.,   Denver,   Colo. 
Bosworth,  Robinson,  St.  Paul,  Minn. 
Bowen,  William,   Knoxville,  Tenn. 
Briggs,   L.   Vernon,   Boston,   Mass. 
Brockway,  Robt.  O.,  Brooklyn.  N.  Y. 
Brooks,    Harlow,    New     York    City. 
Brown,  Alex.  G.,  Richmond,  Va. 
Brown,   Samuel   S.,   Brooklyn,   N.   Y. 
Buesser,  Fredk.  G.,  Detroit,  Mich. 
Bumsted,  C.  R.,  Newark,   N.  J. 
Bunker,  Henry  A..   Brooklyn,  N.   H. 
Burns,    G.    H.,    Central    Islip,    N.    Y. 
Burrage,  Thomas  J.,  Portland,  Me. 
Butler.  Glent.  R.,  Brooklyn,  N.  Y. 
Byrne,  Jos.  Henry,   New   York  City. 

Caille,  August,  New  York  City,  N.  Y. 
Calvert,    W.    J.,    Dallas,    Tex. 


Carman,   Albro   R..   New    York  City. 
Cassidy,  John   M.,  Jersey  City,  N.  J. 
Chapin,    Edward,    Brooklyn,    N.    Y. 
Cliristie,  Arthur  C,  Corry,   Pa. 
Cluircliill,    Jas.    F.,    San    Diego,    Cal. 
Clark,   Ramond,   Brooklyn,   N.    Y. 
Cohen,  Bernard,  Buffalo,  N.  Y. 
Collins,  Danl.  W.,  Wilkes-Barre,  Pa. 
Conklin,  C.  B.,  Washington,  D.  C. 
Connolly,  Richard  N.,  Newark,  N.  J. 
Connor,    Guy    L.,    Detroit,    Mich. 
Conway,  F.  C,  Albany,  N.  Y. 
Cooper,    W.    G.,    Ogdcnsburg,    N.    Y. 
Corbus,   B.   R.,  Grand    Rapids,   Mich. 
Cornwall,   E.   E.,    Brooklyn,   N.   Y. 
Coughlin,  Robert  E.,  Brooklyn,  N.  Y. 
Coulter,  F.  E.,  Omaha,  Neb. 
Crafts,  Leo  M.,  Minneapolis,  Minn. 
Cramp,    Arthur    J.,    Chicago,    111. 
Croftan,   Alfred   C,   Chicago,    111. 
Cruikshank,  Wm.  J.,  Brooklyn,  N.  Y'. 
Cullings,  Jesse  J.,  Memphis,  Tenn. 
Cummings,    Rol.,    Los    Angeles,    Cal. 
Curtis.    Grant    P.,   Union,    N.   J. 
Cutter,    William    W.,    Peoria,    111. 

Daland,   Judson,    Philadelphia,    Pa. 
Dattelbaum,  M.  J.,  Brooklyn,  N.  Y. 
Davin,    John    P.,    New    York   City. 
Dawes,  Spencer  L.,  New  York  City. 
De  Buys,  L.  R.,  New  Orleans,  La. 
De  Lorme,  M.  F.,  Brooklyn,  N.  Y. 
Dercum,    Francis    X.,    Phila.,    Pa. 
De  Yoanna,  A.,  Brooklyn,  N.  Y. 
Dickinson,    H.    S.,    Philadelphia    ,Pa. 
Diner,  Jacob,  New  York  City,  N.  Y. 
Dill,  George  H.,   Utica,  N.  Y. 
Dol)kin,    Nicholas,    Brooklyn,    N.    Y. 
Donovan,  Daniel  J.,  New  York  City. 
Dowd,    Ambrose    F.,    Newark,    N.    J. 
Dowden,   C.   W.,  Louisville,   Ky. 
Dunklin,   F.   B.,   Nashville,  Tenn. 

Eckel,   John   L.,    Buffalo,   N.   Y. 
Edson,   David   Orr,   New   York  City. 
Egan,  Cornelius  J.,  New  York  City. 
Eichler,  Philip,  Bronx,  New  York. 
Elliott,    Daniel,    Newark,    N.    J. 
Evans,  Britton  D.,  Greystone,   N.  J. 
Evans,   George   A.,   Brooklyn,   N.   Y. 

Fairbairn,  Henry  A.,  Brooklyn,  N.  Y. 
Fassett,  Chas.  W.,  Kansas  City,  Mo. 
Faust,  Louis,  Schenectady,  N.  Y. 
Field,  C.  Everett.  New  York  City. 
Finck,  T.  D.,  Louisville,  Ky. 
Fishbaugh.  E.  C,  Los  Angeles,  Cal. 
Fisiier,  Charles  M.,  Brooklyn,  N.  Y. 


118    THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 


Fisher,  E.   M.,  Greystone   Pk.,  N.  J. 
Flagge,  Fredk.  W.,  Rockaway,  N.  J. 
Fleischaker.    F.    W.,    Louisville,    Ky. 
Fliedner,    G.    B.,    Cleveland,    O. 
Fontaine,  Bryce  W.,  Memphis,  Tenn. 
Friedman,  G.  A.,  New  York  City. 
Friend,   John   M.,   Cleveland,   O. 
Fuller,  Frank  M.,  Keokuk,  la. 
Futterer,    Gus.   A.,    Chicago,    111. 

Gaertner,    Fredk.,    Pittsburgh,    Pa. 
Gehring,   E.   W.,   Portland,   Me. 
George,   S.,   Pittsburgh,   Pa. 
Gerin,  John,  Auburn,  N.  Y. 
Gibson,  Arthur  R.,  Buffalo,  N.  Y. 
Gilfillan,  W.  White.,  New  York  City. 
Goddard,  W.  W.,  Schenectady,  N.  Y. 
Gompertz,  L.  M.,  New  Haven,  Conn. 
Gordon,   Alfred,    Philadelphia,    Pa. 
Gordon,  Murray  B.,  Brooklyn,  N.  Y. 
Gottlieb,    Charles,   New   York   City. 
(Jould,  L.  A.,  Schenectady,  N.  Y. 
Grandy,   Charles   R.,   Norfolk,   Va. 
Granger,  Frank  B.,  Boston,  Mass. 
Graves,    M.    L.,    Galveston,   Tex. 
Graves,   Nathaniel   A.,   Chicago,    111. 
Grayson,  Gary  T.,  Washington,  D.  C. 
Grayson    Thos.    W.,    Pittsburgh,    Pa. 
Gray,  T.   N.,   East  Orange,   N.  J. 
Greeff,  J.  G.  Wm.,  New  York  City. 
Greene,    Chas.    L.,    St.    Paul,    Minn. 
Greiwe,   John   E.,   Cincinnati,   O. 
Griswold,    Alex.    V.,    Louisville,    Ky. 
Gutman,   J.,    Brooklyn,    N.    Y. 

Hall,  Josiah   N.,   Denver,   Colo. 
Halpern,  J.,  New  York  City,  N.  Y. 
Haass,   E.   W.,   Detroit,  Mich. 
Ham,    Still.,    S.,    Schenectady,    N.   Y. 
Hamilton,   H.   D.,   Kansas   City,   Mo. 
Hangarter,  And.  H.,  Brooklyn,  N.  Y. 
Harrison,  Bev.  Drake,  Detroit,  Mich. 
Hatch,  J.  Leffing'll,  New  York  City. 
Head,    Geo.    D.,    Minneapolis,    Minn. 
Heller,   Jos.    M.,   Washington,   D.   C. 
Hemmeter,  John   C,   Baltimore,   Md. 
Henderson,   Max,   Louisville,   Ky. 
Henschel,  L.  K.,  Greystone  Pk.,  N.  J. 
Heussy,  Wm.  C,  Seattle,  Wash. 
Hiatt,  Houston  B.,  High  Point,  N.  C. 
Hickey,    Preston    M.,    Detroit,    Mich. 
Hill,   Eben   C,   Poughkeepsie,   N.   Y. 
Hodges,   Fred    M.,   Richmond,   Va. 
Hodges,  J.  Allison,  Richmond,  Va. 
Hoff,   Peder  A.,  St.  Paul,  Minn. 
Hollis,    A.    Wm.,    New    York    City. 
Hollister,  Frank  C,  New  York  City. 
Horine,  Emmet  F.,  Louisville,  Ky. 
Horowitz.   Philip,  New  York  City. 
Hoxsie,  Edward  H.,  Brooklyn.  N.  Y. 
Hubbard,   W.   S.,   Brooklyn,   N.   Y. 


Hunt,   Edward   L.,   New   York    City. 
Hunter,   Geo.   G.,   Los   Angeles,    Cal. 

Irwin,  J.   W.,   Louisville,   Ky. 
Ives,  AjUgustus   W.,   Detroit,  Mich. 
Ives,   Robert  F.,  Brooklyn,  N.   Y. 

Jackson,   Algernon    B.,    Phila.,    Pa. 
Jackson,  Edw.  W.,  Rochester,  N.   Y. 
Jager,   Thor,   Wichita,   Kan. 
Jelly,   Artliur   C,    Boston,   Mass. 
Jenkins,   Wm.   A.,   Louisville,   Ky. 
Jennings,    C.    G.,    Detroit,    Mich. 
Johnston,  George  C,  Pittsburgh,  Pa. 
Johnston,   J.    I.,    Pittsburgh,    Pa. 
Jonah,  Wm.  E.,  Atlantic  City,  N.  J. 
Jones,  Allen   A.,   Buffalo,   N.   Y. 
Jones,    Clement    R.,    Pittsburgh,    Pa. 
Jones  Frank  A.,   Memphis,  Tenn. 
Jutte,   Max   Ernest,   New   York  City. 

Katzenbach.  W.  H.,  New  York  City. 
Kaufman,  Albert,   Wilkes-Barre,   Pa. 
Kaufman,    F.   J.,    Syracuse.    N.    Y. 
Kaufman,  Jacob,   New   York   City. 
Kauffman,   Lesser,   Buffalo,   N.    Y. 
Kelly,    Thomas,    New    York    City. 
Kerr,  Le  Grand,  Brooklyn,  N.  Y. 
Keyes,    F.    P.,    Brooklyn,    N.    Y. 
Kiefer,    Guy    S.,    Detroit.    Mich. 
King,  George  W.,  Secaucus,  N.  J. 
King,   Samuel   T.,  Brooklyn,   N.  Y. 
Kiser,    Edgar    F.,    Indianapolis,    Ind. 
Klein,  Abraham,  Brooklyn,  N.  Y. 
Knapp,   Philip  C,  Boston,  Mass. 
Krafft,  Jacob  C,  Chicago,  111. 
Kraker,   David  A.,  Newark,   N.  J. 
Laporte,   Geo.   L.,   New  York   City. 
Lappeus,  J.  C.  S.,  Binghamton,  N.  Y. 
Lath,   Eugene   M.,   Rochester,   N.   Y. 
Lee,  John,   Detroit,   Mich. 
Lee,  Thomas   S.,  Washington,   D.   C. 
Levy,   I.   Harris,   Syracuse,   N.   Y. 
Levy,   I.   J.,   New   York   City,    N.   Y. 
Levy,   Louis   H.,   New   Haven,   Conn. 
Le  Wald,  Leon  T.,  New  York  City. 
Lewi,  Emily,  New  York  City,  N.  Y. 
Lewis,  H.  Edwin,  New  York  City. 
Lichty,   John   A.,    Pittsburgh,    Pa. 
Litchfield,  Lawrence.  Pittsburgh,  Pa. 
Little,  George  F.,  Brooklyn,  N.  Y. 
Loewenburg,    Saml.   A.,    Phila.,    Pa. 
Louria,   Leon,   Brooklyn,   N.   Y. 
Love,   F.   W.   Buffalo,   N.   Y. 
Love,   Wm.   S.,   Baltimore,   Md. 
Loveland,  B.  C,  Syracuse,  N.  Y. 
Lowrey,  James  H.,  Newark.   N.  J. 
Lucas,   C.   G.,  Louisville,   Ky. 
Ludlum   W.   D.,   Brooklyn,   N.   Y. 
Lynch,  John  C,  Bridgeport.  Conn. 
Lytle,  Albert  T.,  Buffalo,  N.  Y. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      119 


Magruder,  W.  Edw.,  Baltimore,  Md. 
Alaier  Otto,   New   York   City,   N.   V. 
Mallory,   Wm.  J.,  Washington,  D.  C. 
Alannheimer,  George,  New  York  City. 
Martland,  Harrison  S.,  Newark,  N  J. 
Matson,    Ralph    C,    Portland,    Ore. 
Mayer,   Edw.   E.,    Pittsl)urgii,   Pa. 
Mayhew,   John    Mills,    Lincoln,    Neb. 
Mcling,    Nelson    C,    Chicago,    111. 
Meltzer,    Victor,    New    York    City. 
Mercnr,  Wm.  H.,  Pittsburgh,  Pa. 
Meiier,  S.  H.,  New  York  City,  N.  Y. 
Meyers,    Sidney    J.,    Louisville,    Ky. 
Monae-Lesser,    Mozart,    N.    Y.    City. 
Mooney,  Louis  M.,  New   York  City. 
Moren,  John  J.,  Louisville,   Ky. 
Morgan,  Jas.   D.,  Washington,  D.  C. 
Morgan,  Wm.  G.,  Washington,  D.  C. 
Morrison,  A.  W..  Minneapolis,  Minn. 
Moses,   Henry   M.,   Brooklyn,    N.   Y. 
Mulligan,  Wes.  T.,  Rochester,  N.  Y. 
McBlaine,  T.  J.,  Niagara  Falls,  N.  Y. 
McCaskey,  Geo.  W.,  Ft.  Wayne,  Ind. 
McClanahan,  H.  M.,  Omaha,  Neb. 
McCreedy,    E.    B.,    Pittsburgh,    Pa. 
MacEvitt,  James  M.,  Brooklyn,  N.  Y. 
McGraw,   T.   A.,   Jr.,   Detroit,    Mich. 
McGruder,  W.  Edw..  Baltimore,  Md. 
McPherson,  O.   P.,  Kansas  City  Mo. 
McSweeny,   E.   S.,   Staten   Is.,   N.   Y. 

Nash,    Philip    I.,    Brooklyn,    N.    Y. 
Nilson,  C.  Stuart,  Tacoma,  Wash. 
Norbury,  Frank  P.,  Springfield,  111. 
Norden,   H.   A.,   Chicago,   111. 
Norred,  C.  H.,  Minneapolis,  Minn. 
Northridge,  W.  A.,  Brooklyn,  N.  Y. 

O'Mara,  John   T.,   Baltimore,   Md. 
Orbison,  Thos.  J.,  Los  Angeles,  Cal. 
Overton,   W.  T.,  Binghamton,   N.   Y. 

Patek,  Arthur  J..  Milwaukee,  Wis. 
Pease,  Marshall  C,  New  York  City. 
Pettit,    Albert,     Pittsburgh,    a. 
Pfeiffer,    Felix,    New    Y'ork    City. 
Philips,    Carlin,    New    York    City. 
Pogges,   Wm.   S.,    Louisville,    Ky. 
Pollak,   B.    S.,   Secaucus,    N.   J. 
Polozker,     I.     L.,    Detroit.     Mich. 
Pottenger,     F.     M.,     Monrovia,     Cal. 
Prendergast,  Jas.  F.,  New  York  City. 
Pryor,  John  H.,  Buffalo,  N.  Y. 
Pumpyea,    P.    C,    New    ^'ork   City. 
Putnam,   James   W.,    Buffalo,    N.   Y. 

Quackenbos,  H.  F.,  New  York  City. 
Quintard,   Edward,   New   York   City. 

Ramirez,   Max  A.,   New    York   City. 


Reed,   Edw.    H.,   Washington.   D.   C. 
Reed,  Fred  C,  Schenectady,  N.  Y. 
Reed.  Ralph  G.,  Central   Islip.  N.  Y. 
Reeves,    Rufus    S.,    Philadeli)hia,    Pa. 
Reifenstein,    E.    C,    Syracuse,    N.    Y. 
Reilly,  T.  F.,  New  York  City,  N.  Y. 
Rcvnolds,  Herl)ert  S.,  Clinton,  Conn. 
Rice.   James    F.,    Buffalo,    N.    Y. 
Richardson,  E.  J.,  New  York  City. 
Robertson,  F.  W.,  New  York  City. 
Robinson,    D.,    New    York    City. 
Rochester,  Delancey.  Buffalo,  N.  Y. 
Roebuck.  L.  L.,  Richwood,  (X 
Roonoy  James   F.,  Albany,   N.  Y. 
Rothenl)erg,  L.   H.,   New   York  City. 
Rottenberg,  I.  M.,  New  York  City. 
Roussel.  Albert  E.,  Philadelphia,  Pa. 
Roy,   Pliilip   S.,  Washington,   D.  C. 

Sachs,  Adolph,  Omaha,  Neb. 
Sachs.  L.  B.,  New  York  City,  N.  Y. 
Sajous   Chas.    E.   de   M.,    Phila.,    Pa. 
Salzman,   Samuel,  Toledo,  O. 
Satterlee,  F.  Leroy,  New  York  City. 
Satterthwaite,  T.  E.,  New  York  City. 
Schapira,    S.   Wm.,   New   York   City. 
Schlapp,    Max    G.,    New    York    City. 
Schweikhart,  Fred.  J.,  Elmhurst,  N.  Y. 
Scott,    George    D.,    New    York    City. 
Scott,  J.  M.  W.,  Schenectady,  N.  Y. 
Seufert,  E.   C,   Chicago,   111. 
Shearer,  Thos.  L.,  Baltimore,  Md. 
Sheldon    Wm.    H.,    New    York    City. 
Sherman,   G.   H.,   Detroit,   Mich. 
Sillo,    Valdemar,    New    York   City. 
Slaymaker,   Samuel   R.,  Chicago,   111. 
Smith,  A.  D.,  Brooklyn,  N.  Y. 
Smith,    Ernest    B.,    Philadelphia,    Pa. 
Smith,  John   Hall,   Boston,   Mass. 
Smith,  Joseph  E.,  Brooklyn,  N.  Y. 
Smithies,  Frank,  Chicago,  111. 
Schiland,    Albert,    Los    Angeles,    Cal. 
Somers,  J.   A.,   Brooklyn,   N.   Y. 
Stapleton,  Wm.  J.,  Detroit,  Mich. 
Stark,  M.,  New  York  City,  N.  Y. 
Stearns,    Wm.    G.,    Chicago,    111. 
Steiner,    Edwin,    Newark,    N.   J. 
Stella  Antonio,  New   York  City. 
Stern,   Heinricb,   New   York   City. 
Stewart,  C.  E.,  Battle  Creek,  Mich. 
Stewart,  F.  E.,   Philadelphia,   Pa. 
Stewart,   W.  B.,  Atlantic   City   N.   J. 
Stewart,    W.    H.,    New    York    City. 
Stillman,  Edgar  R..  Troy,  N.  Y. 
Stith,   Robert   xM.,   Seattle,   Wash. 
Stone,  Warren  B..  Schenectady,  N.Y. 
Stoner,   Willard   C,   Cleveland,   O. 
Strietmann,    Wm.   H.,   Oakland,   Cal. 
Strodl,   George   T.,   New   York   City. 
Swan,  John  M.,  Rochester,  N.  Y. 
Swink,    Walter   T.,    Memphis,    Tenn. 


120    THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 


Teeter,  Charles  E.,  Newark,  N.  J. 
Thorne,  F.   H.,  Greystone  Pk.,  N.  J. 
Thorne,   J.    M.,    Pittsburgh,    Pa. 
Tice,  Frederick,  Chicago,  III. 
Tichenor,   G.   H.,  Jr.,   New   Orleans. 
Titus,   Edward    C.,    New    York   City. 
Trapp,  Albert  R.,  Springfield,  111. 
Tuley    Henry    Enos,    Louisville,    Ky. 
Tuohy,  E.  L.,  Duluth,  Minn. 
Turck,  Fenton  B.,  New  York  City. 

Ullman,  Julius,  Buffalo,  N.  Y. 
Updegraff,    Ralph    K.,   Cleveland,    O. 
Upshur,  John  N.,  Richmond,  Va. 

Van  Cott  J.  M.,  Brooklyn,  N.  Y. 
Vander  Bogart,  F.,  Schenectady,  N.Y. 
Vander   Hoof,   D.,   Richmond,   Va. 
Van  Wart,  R.  M.,  New  Orleans,  La. 
Vaux,  Chas.  L.,  Central   Islip,  N.  Y. 
Verbrycke,  J.   R.,   Washington,   D.  C. 
Vickery,  Herman  F.,  Boston,  Mass. 
Visscher  Louis  G.,  Los  Angeles,  Cal. 
Von  Ruck,  Karl,  Asheville,  N.  C. 
Von  Ruck,  Silvio,  Asheville,  N.  C. 
von   Tiling,   J.   H.   M.   A., 

Poughkeepsie,  N.  Y. 
Voorsanger,  Wm.  C,  San  Fran.,  Cal. 

Wachsmann,    S.,    New    York    City. 
Walsh,  Thomas  J.,  Buffalo,  N.  Y. 


Walter,   Josephine,   New   York   City. 
Warfield,  Louis  M.,  Milwaukee,  Wis. 
Warmuth,    M.    P.,    Philadelphia,    Pa. 
Warren,  L.  F.  Brooklyn  N.  Y. 
Watkins,  John  T.,  Detroit,  Mich. 
Weber,  Leonard  G.,  New  York  City. 
Webster,  Henry  G.,  Brooklyn,  N.  Y. 
Weinstein,    J.    W.,    New    York    City. 
Welker,   Franklin,   New   York   City. 
Wendel,   Henry   C,   Cincinnati,   O. 
Wessels,    W.    F.,    Los    Angeles,    Cal. 
Westervelt,    H.    C,    Pittsburgh,    Pa. 
Wheeler,  Robert  T.,  Brooklyn  N.  Y. 
Whelan,  Edward  P.,  Nutley,  N.  J. 
Wholey,  C.  C,  Pittsburgh,   Pa. 
Wilcox,    R.    W.,    New    York    City. 
Williams,    B.    G.    R.,    Paris,    111. 
Williams,  J.   R.,   Rochester,   N.   Y. 
Wills,    Guillermo,    New    York    City. 
Wilson,  C.  Stuart,  Tacoma,  Wash. 
Winter,  Henry  Lyle,  Cornwall,  N.  Y. 
Wiseman,  Jos.  R.,  Syracuse,  N.  Y. 
Witherspoon,   J.  A.,  Nashville,  Tenn. 
Witter  Orin  R.,  Hartford,  Conn. 
Wolf,    I.   J.,   Kansas   City,   Mo. 

Youngling,  Geo.  S.,  New  York  City. 

Zbinden,  Theodore,  Toledo,  O. 
Zueblin,  Ernest,  Baltimore,  Md. 
Zugsmith,    Edwin,    Pittsburgh,   Pa. 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

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This  book  is  DUE  on  the  last  date  stamped  below. 


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